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It 

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1 

2 

3 

32X 


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#»4*«»*i»«***'**'' 


THE  FAIRCHILD  PREPARATIONS 


OX' 


THE  mi  mimn  feeiienis, 

Active,  Permanent  and  Reliable. 


TRYPSIN 

(FAlRCniI,D) 

Especially  Pri pared  as  a  Sohietit  for 
Diphtheritic  Metiuircnt. 


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(FAlkCllILIl). 

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of  the  Pancreas. 


PEPTONISING  TUBES. 

(KAIRClUI.t)). 

For    the  preparation   of  PEPTO- 
NIZED MILK  and  other 
predigested  food  for 
the   sick. 


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(kaiuciiild). 

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to  the  standard  of  A'ormal 

Mother's  Milk. 


PEPSINE   IN  SCALES. 

(fairciiild). 

The  most  active,  permanent  and  re- 
liable pepsine  made  in  the  World. 


ESSENCE  OF  PEPSINE 

(FAIRCHILD). 

For  administration   where  a  fluid 
and  agreeable  form  of  pepsine  is 
desired,  and  for  the  prepara- 
tion of  Junket   and 
fVhey. 


PEPSINE  IN  POWDER. 

(FAIRCHILD). 

Prepared  from  the  scales  mithout  the 
admixture   of  .iny  other  sub- 
stances, to  facilitate  dis- 
pensing and  the  pre- 
paration of  sacchara  ted  pepsine. 


DIASTASIC    ESSENCE  OF 
PANCREAS. 

(FAIRCHILD). 

For  the   digestion  of  starchy  foods. 


Fairchild  Bros.  &   Foster, 

82  and  84  fulton  st.,  new  york. 


*9*»<«-«fc^?iiAH:^'»«jtoel4;tiu-r«S^*-i'-^^!^^ 


V 


A  TREATISE 


NEURALGIA 


E.  P.  HJJRD,  M,   D., 

Mtmbtr  of  the  Massaehuselts  Medical  Sociity;  Member  of  the  Climato- 

hgical  Socitty;  Member  o/theSocieU  de  Midecine  Pratique 

{Paris,  France).     One  of  the  physicians  to  the  Anna 

Jaquu  Hospital,  Newburyport.  Mass. 


'4 


V^' 


1890. 
GBORGE  S,  DAVIS, 

UBTROIT,  MICH. 


■APS^.^-*«::§5T,g.i^St*(^'>ijW«.iftati>^V«V=i-«.a/ft.v^i*tfa;.t. 


'.:f 


J- 


Co|  yiiirltiiit  liy 
CIKiilidK  S,   1)A\'IS 


ft- 


i 


DEDICATED 
TO  DUJARDIN  FJEAUMETZ, 

rHO    HAS    DONE   SO   MUCH    TO   ADVANCE  TIIEHAPEUTICS, 
BY  HIS  FRIKNI), 

THE    WRITER. 


'  ■Mi^i*afe-!H;ir^JW*=»Jri 


TABLE  OF  CONTENTS. 

CHAPTER  I. 

PaC«. 

General  Conilderations  on  Neuralgia i_i8 

CHAPTER  11, 
Claailfication  of  the  Neuralgias i^aj 

CPAPTER  III. 
The  Causes  of  Neuralgia 24-30 

CHAPTER  IV. 
Particular  Forms  of  Neuralgia 31-56 

CHAPTER  V. 
Visceral  Neuralgias 57-70 

CHAPTER  VI. 

Reflex  and  Toxic  Neuralgias;  Neuralgias  Due  to  a  Gen- 
eral M jrbid  Condition 7i-8a 

CHAPTER  VII. 
Diagnosis 93-91 

CHAPTER  VIII, 
Prognosis ^j 

CHAPTER  IX. 
The  Treatment  of  Neuralgia 94-106 

CHAPTER  X. 
Appendix 107-143 


CHAPTER  I. 

GENERAL  CONSIDERATIONS  ON  NEURALGIA. 

Pain  is  a  fact  of  consciousness,  having  for  its 
invariable  antecedent  a  disturbance  of  a  sensory  nerve 
or  nerve-centre.  Its  seat  is  that  part  of  the  cerebral 
cortex  known  as  the  sensorium;  the  cause  is  generally 
an  abnormal  modification  of  some  part  of  a  nerve  of 
sensation.  The  function  of  sensory  nerves  being  to 
convey  impressions  to  the  sensorium,*  when  such  im- 
pressions are  abnormal  in  kind  or  in  intensity,  the 
phenomenon  of  pain  may  arise.  One  of  the  most  com- 
mon excitants  of  pain  is  inflammation,  which  causes 
compression  of  the  nerves  of  a  region  and  disturb- 
ance of  their  nutrition  and  function.  Another  cause 
is  antemia,  or  want  of  blood,  for  no  pain  is  more  in- 
tense than  that  which  is  experienced  in  a  limb  whose 
supply  of  blood  is  cut  off  by  an  arterial  embolus. 
Tumors,  foreign  bodies  as  splinters,  wounds  or 
compression  of  nerves,  also  bring  about  those  molecular 
changes  in  sensory  conductors  whose  conscious  expres- 
sion is  pain;  and  the  same  may  be  said  of  an  inflamma- 
tion  confined  to  the  sheath  of  the  nerve  itself.     In  fact, 


•  By  the  term  sensorium,  I  understood  with  Robin,  that 
portion  of  the  encephalon  which  perceives,  as  distinguished 
from  that  which  thinks,  and  fiom  that  which  is  endowed  with 
motricity. 


pain  may  be  looked  upon  as  a  cry  of  danger,  as  an 
index  of  a  destructive  process  somewhere  going  on  in 
the  organism. 

IVIany  iiinds  of  pain  have  l<nown  pathological  con- 
ditions for  their  substratum;  the  pain  is  the  result  of 
a  phlegmon,  a  tumor,  etc.  This  is  not  the  case  with 
the  kind  of  pain  of  which  we  are  here  to  treat,  for 
neuralgia  belongs  to  a  class  of  nervous  diseases 
known  as  neuroses— i.  <?.,  which  are  functional  or  dyna- 
mic,   not  dependent  on  any  gross  anatomical  lesion. 

Neuralgia  is  a  neurosis  whose  essential  symptom 
consists  in  a  lancinating  pain,  paroxysmal  in  character, 
described  as  boring,  burning,  stabbing,  localized  in 
particular  nerve-trunks  or  their  terminal  branches; 
apyretic,  without  redness,  without  tension  or  apparent 
swelling;  generally  accompanied  by  secondary  phe- 
nomena of  a  motor,  vaso-motor,  secretory,  or  trophic 

nature.* 

Spring  thinks  that  in  order  that  the  word  neural- 
gia should  be  applicable  to  any  particular  case,  there 
should  exist  two  conditions:  i,  the  pain  should  be 
paroxysmal  in  character;  2,  there  should  be  no  peri- 
pheral or  central  lesions  present.f 

Gowers  would  restrict  the  name  neuralgia  to  the 
idiopathic  class,  and  would  exclude  all  forms  (among 

•  The  throbs  of  pain  someiimes  coincide  with  the  arterial 
pulsations  (Gowers.) 

\  Dujardin  Beaumeiz,  "  Clinical  Theri.pputics,"  American 

ed.,  p.  51. 


as  an 

on  in 

il  con- 
sult of 
e  with 
at,  for 
seases 
dyna- 
!sion. 
nptoni 
racter, 
'.ed  in 
nches; 
parent 
Y  phe- 
rophic 

leural- 
,  there 
uld  be 
)  peri- 

to  the 
among 

arterial 
merican 


—  3  — 
which  he  thinks  sciatica  generally  belongs)  which  are 
the  result  of  neuritis. 

Genera/  Characteristics. — A  general  feature  of 
neuralgic  cases  is  the  existence  of  annemia  and  debil- 
ity. Anstie  insists  on  this  condition  of  anaemia,  or 
vital  depression,  as  an  invariable  factor  in  neuralgia. 
The  patient  has  been  fatigued  from  overwork,  physi- 
cal or  mental,  or  has  gone  through  an  exhausting  ill- 
ness. Prolonged  suppurations,  haemorrhages,  exces- 
sive venery,  in  fact  debilitating  influences  of  all  kinds, 
may  bring  about  the  neuralgic  diathesis. 

One  of  the  most  severe  and  obstinate  cases  of 
gastralgia  that  I  ever  witnessed  was  in  a  young  woman 
who,  while  nursing  a  robust  infant,  carried  on  the 
work  of  a  large  family  while  living  on  a  meagre  and 
quite  insufficient  diet. 

Another  characteristic  is  that  exhaustion,  from 
any  cause,  brings  on  an  attack  of  pain.  The  victim 
of  hemicrania,  for  instance,  will  have  an  attack  after 
the  fatigue  of  too  long  a  walk,  or  a  night's  watching. 

Another  common  feature  of  the  neuralgias  is  the 
intermittence  of  the  pain.  The  symptoms  are  par- 
oxysmal in  character:  this  is  owing  to  the  law  of 
nervous  exhaustion,  for  nervous  actions  are  not  con- 
tinuous, but  interrupted  by  periods  of  repose,  due  to 
exhaustion  of  the  excitability,  even  when  the  excite- 
ment is  persistent.* 


•Jaccoud,  Pathologic  Interne.     Vol.  i,  p.  485. 


—  4  — 

Inconsequence  of  a  fancied  resemblance  between 
the  phenomena  of  neuralgic  paroxysms  and  those  of 
genuine  intermittent,  Van  Swieten  applies  the  name 
oi  febris  topica  to  the  former,  and  declares  neuralgia 
to  be  only  another  manifestation  of  ague;  with  this 
view  other  ancient  authorities  coincide.*  It  is  not  an 
uncommon  thing  for  a  paroxysm  of  neuralgic  pain  to 
pass  off  after  an  hour  or  two  of  severity,  leaving  a 
state  of  perfect  quiescence;  oftener  however,  it  must 
be  confessed,  a  deep,  contusive,  fixed  or  diffuse  pain 
remains  till  the  next  attack,  which  may  come  on  in  a 
few  hours,  or  not  till  the  sleep  of  the  night  is  over. 
The  resemblance  to  an  access  of  intermittent  fever,  it 
must  be  confessed,  is  superficial  and  slight,  but  the 
paroxysmal  character  is  none  the  less  a  fact. 

Another  event  common  to  all  the  neuralgias  is 
the  occurrence  of  certain  tender  spots  ( points  doul- 
oureaux)  which  are  always  found  in  neuralgias  of  a 
certain  persistence  and  duration.  These  arc  called 
Valleix's  painful  points.  These  painful  spots  are  gen- 
erally situated  at  the  point  where  a  nerve  trunk 
emerges  from  a  bony  foramen,  or  pierces  the  fascia  of 
a  muscle  to  be  distributed  to  the  skin.  These  spots 
are  sometimes  the  centres  of  radiation  of  spontaneous 
pain;  pressure  upon  them  provokes  very  severe  pain 
which  may  intensify  the  neuralgic  attack. 

Lastly,  another  peculiarity  of  neuralgias  is   their 


*  Rowland  On  Neuralgia.     1837. 


veen 
e  of 
ame 
ilgia 

this 
)t  an 
1  to 
ig  a 
nust 
pain 
in  a 
)ver. 
;r,  it 

the 

s  is 
ioul. 
if  a 
ilied 
gen- 
unk 
iaof 
pots 
eous 
pain 

heir 


—  5  — 
generally  unilateral  character.      This  is  so  much  em- 
phasized by  Anstie,  that  it  forms  a  part  of  his  defini- 
tion.* 

Clinical  Description. — As  a  type  of  our  descrip- 
tion, we  will  take  a  case  of  facial  neuralgia,  known 
also  as  neuralgia  of  the  fifth,  or  trigeminus.     The  pa- 
tient may  have  been  well  up  to  the  time  of  the  attack; 
or,  as  is  oftener  the  case,  may  have  been  depressed 
from  cold,  insomnia,  overwork.     Suddenly,  or  after 
certain  premonitions,  as  nausea,  chilliness,  a  sense  of 
weight  about  the  head,  and  a  vague  feeling  of  gen- 
eral discomfort— a  circumscribed  pain  makes  its  ap- 
pearance in  some  point  of  the  face,  or  in  one  of  its 
cavities.     This  pain,  at  first  dull  and  contusive,  soon 
becomes  more  intense,  darts  up  and  down  one  of  the 
main    trunks,    and   affects   simultaneously  numerous 
branches.     The   attack  may  consist  of  a  continuous 
ache,  or  of  a  succession  of  violent  twinges,  with  com- 
parative ease  in  the  intervals.     In  the  height  of  the 
paroxysm,  the  pain  seems  to  shoot  into  every  nerve 
twig  of  the  affected  side,  with  predominance  of  aching 
in  one  particular  spot  where  it  first  started.     A  pecu- 
liarity of  the  pain  is  that  it  manifests  itself  in  a  series 
of  shocks  more  or  less  near  together,  though  each 
series  is  separated   by  an  appreciable  interval;   the 
sum    of  these   series   constitutes  the    attack.      The 


*  Anstie,  Neuralgia  and  the  Diseases  that  Resemble  It, 
New  York,  D.  Appleton  &  Co.,  1883. 


I! 

r:  ■ 

si 

N 

4 


—  6  — 

duration  of  the  paroxysm  is  from  a  quarter  of  an 
hour  to  an  hour  and  a  half;  in  one  inveterate  case,  I 
have  known  the  paroxysms  to  last  all  day,  with  only 
brief  intervals  between.  The  pain  is  increased  and 
even  awakened  by  a  touch  of  the  hand,  while  it  is 
often  the  case  that  gentle  rubbing,  or  even  firm  press- 
ure over  the  affected  part,  produces  alleviation.* 

With  the  pain,  there  is  frequently  spasmodic 
twitching  of  the  neighboring  muscles,  and  sometimes 
rigid  spasm.  The  existence  of  tetany  in  true  neu- 
ralgia is  denied  by  Vanlair,  but  it  has  been  noted  by 
other  writers,  and  the  writer  saw  a  remarkable  instance 
of  contracture  of  the  elevator  muscles  of  the  shoulder 
in  a  severe  case  of  cervico-brachial  neuralgia. f 

Secondary  phenomena  of  a  vaso-motor  kind,  as 
flushing  of  the  affected  region,  copious  lachrymation 
from  the  neighboring  eye,  or  running  from  the  nostril 
on  that  side,  are  frequent  accompaniments  of  the 
attack. 

Pressure  over  Valleix's  points  is  generally  ex- 
ceedingly painful;  these,  in  trigeminal  neuralgia,  are 
at  the  supra-orbital  and  infra-orbital  and  mental 
foramina.  Good  observers,  however,  have  failed  to 
recognize  these  painful  points  in  facial  neuralgia. 


*■• 


I  i 


*  A  short  pressure  is  followed  by  exaggeration  of  the  pain, 
a  prolonged  pressure,  by  diminution  (Romberg).  The  con- 
tinuous pressure  interrupts  conductibility. 

f  Medical  Record,  1876,  page  744. 


an 
e,  I 

)nly 
and 
t  is 
ess- 

jclic 
mes 
leu- 
by 
mce 
Ider 

,  as 

tion 

stril 

the 

ex- 
are 
ntal 
1  to 


>ain, 
con- 


'9^- 


—  7   — 

The  tactile  sensibility  of  the  skin  is  almost  al- 
ways diminished  after  a  time  in  the  neighborhood  of 
the  affected  nerve.     (Buzzard.) 

The  pain  is  very  apt  to  radiate  from  the  affected 
region  to  the  nerves  (sensory  and  motor)  of  neighbor- 
ing regions.  Thus,  in  trigeminal  neuralgia,  we  may 
have  pains  in  the  posterior  cervical  region  and  the 
occiput,  scapulo-clavicular,  intercostal,  and  mammary 
regions.  The  motor  irradiations  consi.st  in  the  clonic 
contractions  (more  rarely  tonic)  already  alluded  to; 
the  muscles  innervated  by  the  facial  nerve  are  con- 
vulsed. When  facial  neuralgia  assumes  this  violent 
form,  it  is  called  /t'c  douleureux.  The  convulsive  shocks 
sometimes  extend  to  the  symmetrical  muscles  of  the 
other  side  of  the  face,  and  even  to  the  muscles  of  the 
trunk  and  limbs. 

The  attack  of  pain  may  pass  off  gradually,  a 
dull  aching  and  a  soreness  remaining  for  some  time, 
or  it  may  end  suddenly,  the  patient  passing,  as  by 
magic,  from  intense  suffering  to  complete  repose. 
The  latter  mode  of  termination  is  especially  likely  to 
follow  a  judicious  anti-neuralgia  treatment. 

THK    PATHOGENY    (»F    NKUKAUUA. 

We  know  very  little  about  the  material  alterations 
which  attend  neuralgia.  We  distinguish  three  phases 
in  the  operation  of  sensory  nerves: 

I.  When  the  conduction  is  normal.  Here  the 
nerve  conducts  to  the  cerebrum  impressions  natural 


'**""'«i*;">%*^=»^ftjetr»f-^'r,t^.-j»r  - 


T 


I 


■■*i4 


—  8    - 

in  quantity  and  quality;  the  resulting  sensations  are 
pleasurable  or  indifferent.  Such  normal  conduction 
is  a  necessary  condition  of  that  correspondence  be- 
tween the  organism  and  its  environment  which  enables 
the  former  to  adjust  itself  to  changes  outside  of  itself. 
A  stimulus  (heat,  cold,  a  touch,  some  chemical  or 
mechanical  irritant,  etc.),  produces  a  certain  effect  of 
a  chemical,  molecular  kind,  on  the  terminal  filaments 
or  trunk  of  a  .sen.sory  nerve — this  molecular  change  is 
propagated  as  a  wave  of  motion  to  the  cord  and  sen- 
sorium,  where  it  produces  the  appropriate  sensori- 
motor responses;  there  is  a  definite  ratio  between  the 
stimulus  and  the  effects  engendered. 

2.  V'hen  the  excitability  is  exaggerated;  this 
state  is  called  hypericsthesia  (excessive  sensibility). 
The  functional  activity  of  the  nerve  is  exalted 
from  intensity  of  the  excitation.  When  this  hyper- 
sensibility  reaches  a  certain  degree  it  becomes  pain, 
but  this  lasts  no  longer,  or  but  little  longer,  than  the 
excitation  which  has  given  rise  to  it.  Instances  of 
this  functional  hyperaesthesia  are  seen  in  all  inflamma- 
tions attended  with  pain. 

3.  When  the  conduction  is  abnormal;  the 
resulting  sensations  are  the  consequence  of  a  morbid 
irritability  of  the  nerves  and  nerve  centres.  This  form 
has  been  called  by  Jaccoud  "spontaneous  hyperjesthe- 
sia,"  and  characterizes  all  the  neuralgias,  "A  morbid 
hyperaesthesia  raised  to  the  potency  of  spontaneous 


re 

in 

R- 

;s 
f. 

jr 

ts 
is 
[1- 
i- 
le 

is 

)• 
:d 

r- 

n, 
le 

of 
a- 

le 
id 
m 
e- 
id 
us 


—  9  — 
pain  constitutes  neuralgia."  'The  word  spontaneous,  as 
here  used,  "does  not  imply  the  absence  of  any  cause 
capable  of  accounting  for  the  anomalous  state  of  the 
nerve;  it  indicates  simply  that  this  anomalous  state  is 
not  linked  to  the  exercise  of  the  function  of  sensibil- 
ity, as  is  the  case  with  a  pain  occurring  in  connection 
with  the  inflammation  of  a  part." 

It  is  difficult  to  find  illustrations  which  can 
make  plain  the  difference  between  these  several 
modes  of  conductibiiity,  and  the  consequent  state  of 
consciousness. 

If  we  place  a  number  of  marbles  in  a  row,  an 
impulse  at  the  proximal  end  of  the  "line  will  be  trans- 
mitted to  the  distal  end  with  a  quality  and  intensity 
corresponding  to  the  force  communicated  to  the  first 
marble  of  the  series.  We  may  suppose  the  molecules 
of  a  sensory  nerve  to  be  so  arranged  that  an  agitation 
at  the  peripheral  end  is  similarly  transmitted.  Im- 
pacts beyond  a  certain  intensity  might  produce  at  the 
central  end  a  shock  which  would  so  disturb  the  sen- 
sorial centers  as  to  give  rise  to  the  phenomenon  of 
pain;  and  yet  there  would  be  a  definite  correspond- 
ence between  these  central  molecular  disturbances 
and  the  amounts  of  peripheral  irritations.  If  we  could 
imagine  that  each  marble  of  that  row  was  composed 
of  something  akin  to  dynamite;  that  there  were  irreg- 
ular, fitful  explosions  all  along  the  line  from  the  most 


•  Jaccoud,  he.  cit. 


"■ll»iTlf«lMtllWXyi'awBfc»«^ 


If 


lO     — 

trifling  causes,  and  that  thft  quantity  and  intensity  of 
the   disturbance   at   the  distal  end  bore  no   propor- 
tion to  the  force  which  started  the  disturbance,  we 
might  have,  perhaps,  a  faint  notion  of  the  condition 
of  the  perturbed  sensory  nerves  in  a  case  of  neuralgia. 
There  certainly  is  no  objection  to  the  hypothesis— 
which  alone  explains  the  facts— that  the  protoplasmic 
molecules  of  certain  portions  of  the  sensory  apparatus 
in  neuralgic  patients  are  in  a  state  of  peculiarly  un- 
stable equilibrium,  at  the  least  provocation  falling  to 
a  lower  plane  and  liberating  force,  which  is  propagated 
as  a  motor- wave  to  the  central  end;  that  such  nerves 
are  by  this  very  instability  and  explosiveness  ill-fitted 
for  their  ordinary  functions  of  conductors  of  sensory 
impressions,  while  always  predisposed  to  be  the  seats 
of  violent  attacks  of  spontaneous  pain. 

Writers  have  objected  to  the  word  hyperasthesia 
as  used  in  connection  with  the  pain  of  neuralgia,  and 
Vanlair  has  substituted  the  word  hyperalgesia.  If  the 
former  term  may  be  supposed  to  mean  exalted  function, 
it  is  manifestly  inappropriate;  if  exalted  irritability,  it  is 
perfectly  proper.  It  does  not  require  a  wide  familiarity 
with  various  kinds  of  pain  to  convince  one  that  where 
there  is  pain,  there  is  increased  excitability  of  a  cer- 
tain nerve  or  nerves;  nor  is  it  difficult,  from  personal 
experience,  to  recall  instances  where  this  hyperesthe- 
sia, by  the  very  fact  of  intensification,  has  run  into 
pain,  as  in   the   sensory  hyperesthesia  attending  an 


—   II   — 

ophthalmia.*  The  pains  from  palpable  organic  causes 
imperceptibly  shade  into  those  properly  regarded  as 
neuralgic,  and  there  is  no  absolute  line  of  demarca- 
tion at  the  origin.  All  kinds  of  pain  have  for  their 
direct  antecedent,  excessive  molecular  transformation,  , 
and  all  are  markedly  influenced  by  anaesthetics,  by 
quiet,  absence  or  removal  of  stimuli;  in  fact,  some 
pains  of  an  undoubted  neuralgic  character  get  well 
as  soon  as  all  periphereal  excitations  are  removed. 

*  Cowers,  in  his  treatise  on  neuralgia,  lays  emphasis  on 
the  argument  by  which  definite  nerve  paths  (or  pain,  and  con 
sequently  definite  nerve  centres  (or  pain  in  the  cerebrum  are 
a(Brmed.     Thus,  tactile  impressions  pass  up  to  the  brain  in  the 
posterior  columns.  pain(ul  impressions  and  impressions  o(  heat 
in  the  gray  substance,  as  shown  by  experiments  on  animals 
and  by  clinical  observations.     In  some  Instances  (as  cases  o( 
hysteria)  there  is  conservation  o(  the  sense  o(  touch  and  want 
of   appreciation  o(    pain.     Chloroform  abolishes   pain   while 
oden  in  the  ansesthesia  o(  chloroform  sensibility  to  touch  re- 
mains.     Then,  again,  there  is  the  electric  sense  and  the  sense 
of  tickling,  which  are  modalities  of  the  sense  o(  touch,  and 
which   under  some   circumstances  are  abolished,  while  other 
forms  of  sensibility  persist.     Brown  Sequard  has  done  much 
toward  the  demonstration  if  not  mystification  of  this  subject; 
among  those  who  insist  on  definite  specialization  of  nerve  fibres 
and  centres  (or  the  various  modalities  of  sensation,  we  may 
mention  Herzen,  Magnus  Blix,  Donaldson,  and  Goldscheider. 

It  cannot,  however,  be  said  that  there  is  yet  anything 
like  agreement  among  physiologists  respecting  this  vexed  ques- 
tion, and  we  find  Vulpian  maintaining  to  the  last  as  the  result  of 
his  experimentation  the  doctrine  of  "  indifferent  conductibility. 
That  pain  is  not  something  special,  underlved  from  and 


5->iaMUi..  *^-^j"-^  ^'  •■■ 


n 


—    13    — 

The  causes  of  neutulgic  hyperesthesia  may  be 
arranged  in  three  orders*: 

1.  Intrinsic  and  primary  modifications  of  the 
excitability  of  the  nerve  itself  in  some  jwrt  of  its  tract 
from  the  gray  nucleus  of  its  origin  to  its  terminal  ex- 
pansir)ns. 

2.  Extrinsic  lesions,  which  act  directly,  or  indi- 
rectly by  reflex  action. 

3.  Constitutional  states  which  modify  the  ner- 
vous excitability,  generally  by  the  intermediation  of 
an  alteration  of  the  blood. 

The  first  group  contains  tht  primary,  or  essential 
neuralgias;  the  other  two  groups,  the  secondary, 
called  sympathetic  or  symptomatic  neuralgias. 

An  example  of  primary  idiopathic  neuralgia  is 
seen  in  face-ache  (prosopalgia)  from  cold.  Examples 
of  neuralgia  due  to  extrinsic  lesions  acting  directly, 
are  seen  in  attacks  of  proso])algia  starting  in  dental 


separate  from  ordinary  sensibility,  is  seen  in  the  fact  that  there 
is  no  particular  exciting  agent  productive  of  pain;  the  exagger- 
ation of  any  Itind  of  special  sensibility  may  produce  it;— too 
strong  a  light  by  affecting  injuriously  the  retina,  sounds  too  in- 
tense by  violent  agitation  of  the  auditory  nerve,  thermic  excita- 
tions carried  to  the  extreme,  intense  cold,  sufficient  to  produce 
disorganization  of  the  tissues  (Mathias  Duval).  Duval's  defi- 
nition of  pain  is  a  fairly  good  one:  "  Pain  is  constituted  by  a 
modality  in  the  functionment  of  the  centres,  due  to  the  fact 
that  impressioning  agents  act  in  a  violent,  exaggerated  manner, 
and  inflict  a  perturbation  on  the  organs  of  sensibility." 
*  Vide  Jaccoud,  /«•,,  eit.  article,  Ntvralgie. 


Jl 


be 

he 
ict 

iX- 

ii- 

;r- 
of 

ial 
T, 

is 
es 

ly. 

:al 

!re 

er- 

00 

In- 
ta- 
ice 
:fi- 
a 
ict 
er, 


—   13  — 

caries,  or  a  tumor  involv  og  a  branch  of  the  frige- 
minus;  such  lesions  have  bocii  known  to  awaken  neu- 
ralgic paroxysms  inchstinguishablc  from  those  of 
idiopathic  prosopalgia.  Illustrations  of  npnraljfia 
from  reflex  causes  are  seen  in  trigeminal,  cervico- 
brachial,  or  intercostal  neuralgias,  originating  in  ovar- 
itis, or  some  other  affection  of  a  remote  organ. 

Exami)les  imder  the  third  head  arc  seen  in 
neuralgias  due  to  lead  poisoning,  mercurial  poi- 
soning,  syphilis,  or  malaria.  The  neuralgias  accom- 
panying anremia  and  chlorosis  are  also  generally 
classed  under  this  head,  being  due  to  blood  deprave- 
ment. 

Is  it  possible,  from  the  knowledge  which  physiol- 
ogy  gives  us  of  the  ccmstitution  of  nerves,  to  come 
any  nearer  to  an  understanding  of  the  phenomena 
which  take  place  in  neuralgia? 

The  conductibility  of  nerves  is  a  property  inher- 
ent in  the  axis  cylinder,  which  is  the  central  core  of 
the  nerve,  and  is  composed  of  protoplasm.  The  ulti- 
mate peripheral  termination  of  sensory  nerves  is  the 
naked  cylinder.  On  these  protoplasmic  filaments, 
which  in  many  parts  of  the  body  terminate  in  sundry 
appliances  (Paccinian  corpuscles)  which  arc  "  multi- 
pliers of  disturbance,"  and  have  the  function  of  con- 
centrating on  the  nerve  ends  the  action  of  external 
agents,  come  a  multitude  of  impressions  from  the 
outer  world,  from  the  tissues  in  which  these  nerves 
ramify,  and  from  the  circulating  blood.     What  is  the 


IT 


5'; 


—    14   — 

kind  of  change  which  is  produced  when  an  impression, 
as  of  contact,  of  heat,  or  of  cold,  is  made  on  these 
sensory  filaments?  The  only  tenable  supposition  is, 
that  a  wave  of  molecular  disturbance— akin  to  tha 
modification  in  a  telegraph  wire  when  a  message  is 
sent— is  instantly  propagated  the  whole  length  of  the 
nerve  to  its  central  nucleus.  In  the  normal  state  a 
nerve  apparatus  which  is  the  seat  of  such  changes, 
not  inaptly  called  "isomeric  transformations,"  speed- 
ily reintegrates  itself  from  the  circulating  blood,  and 
the  disturbance  does  not  exceed  the  healthy  mean; 
there  is  no  pain.  How  is  it,  when  from  natural  or 
acquired  instability  of  the  nerves,  there  is  too  much 
molecular  tr.uisformation  ? 

Herbert  Spencer  remarks  that  "  the  (peripheral) 
afferent  nerves  of  individuals  who,  though  otherwise 
healthy,  have  lax  tissues,  are  often  unduly  impressi- 
ble." Other  causes  besides  "  lax  tissues  "  may  pro- 
duce this  excess  of  impressibility.  It  may  accompany 
vaso-motor  weakness  and  congestion,  for  local  excess 
of  the  blood  is  attended  with  local  exaltation  of  sen- 
sibility. We  have  to  note,  also,  the  seemingly  anoma- 
lous fact  that  local  deficiency  of  blood,  as  in  anaemia, 
renders  the  nerves  abnormally  impressible.  Ordinary 
excitants  are  capable  of  producing  an  extraordinary 
amount  of  molecular  change.  Cold,  which  is  one  of 
the  normal  excitants,  may,  by  its  prolongation  or  in- 
tensity, bring  about  that  excessive    transformation 


on, 

ese 

I  is, 

tha 

e  is 

the 

:e  a 

?es, 

;ed- 

and 

;an; 

1  or 

uch 

:ral) 

wise 

essi- 

pro- 

lany 

cess 

sen- 

)ma- 

mia, 

nary 

nary 

le  of 

r  in- 

ition 


—  '5  — 
which  finds  expression  in  a  neuralgic  paroxysm.*  A 
mental  shock,  a  physical  injury,  even  a  decayed  tooth, 
may  start  a  disturbance  in  certain  nerve  branches 
which,  not  being  repressed  by  the  higher  nervous  en- 
ergies— co-ordination  being  weakened  or  broken— soon 
amounts  to  a  riot  in  the  organism;  the  central  sensory 
centres  are  fatigued,  overcome,  charged  with  the  pro- 
ducts of  disintegration,  and  brought  to  that  state  of 
molecular  disorder  which  constitutes  algesia,]  and 
whose  conscious  expression  is  pain. 


•  The  modus  operandi  of  cold  may  be  thus  explained.  "It 
exerts  a  depressing  influence  on  the  nervous  centres  in  general. 
The  superficial  layers  of  the  blood  are  cooled;  this  occurs  the 
more  easily  when  the  stimulus  of  chilly  air  is  not  sufficiently 
sharp  and  sudden  to  cause  a  firm  contraction  of  the  cutaneous 
vessels,  while  the  moisture  rapidly  absorbs  the  heat  of  the 
blood.  From  this  result  indirectly  various  disorders  of  nut- 
rition of  the  deeper-lying  tissues  or  distant  organs,  and  among 
these  congestion  and  neuritis  of  the  sensory  nerves." — (Put- 
nam^). 

%  Pepper's  S>8t.  ol  Med.,  vol.  v.,  p.  1219. 

t  A  crm  coined  by  Vanlair  to  denote  the  state  of  the 
central  nerve  cells  whose  manifestation  is  pain.  According  to 
this  writer,  there  are  special  groups  of  cells— not  cells  of  special 
sensation  orgeneralsensibility,— whose  function  iso/^^xtVi/they 
are  set  apart  for  pain  and  nothing  else.  It  must  be  confessed 
that  Vanlair  gives  weighty  arguments  in  support  of  this  view. 
And!  ye'  I  cannot  believe  that  there  arc  nerve  centres  whose 
sole  function  is  the  elaboration  of  painful  sensations.  In  the 
healthy,  normal  sUte,  these  cells  would  have  no  office,  and 
might  be  expected  to  atrophy.    More  reasonable  is  the  doctrine 


—   i6  — 

But  it  will  not  do  to  lose  sight  of  the  fact  that 
neuralgia  may  begin  centrally  as  well  as  peripherally, 
in  a  lowered  state  of  nutrition,  and  in  resulting  dyn- 
amic perturbation  of  the  central  gray  nucleus  itself. 
The  pain  would  be,  as  it  were,  projected  on  the  nerves 
whose  nucleus  is  diseased.  Such  neuralgias  are  ex- 
ceptions. 

The  above  conception — instability  of  the  ultimate 
nerve  elements,  broken  coordination,  brings  neuralgia 
into  harmony  with  the  other  neuroses,  epilepsy,  hys- 
teria, chorea,  etc. 

The  intermittency  of  pain  is  a  consequence  of 
the  intermittent  character  of  nerve  action.  "  If,"  says 
Herbert  Spencer,  "  a  nervous  disturbance  travels  as  a 
wave  of  molecular  change;  if  tliis  wave  is  such  that 
the  molecules  of  nerve  substance  fall  from  one  of  their 


that  pain  is  only  a  modification  of  common  sensibility  and  is  a 
property  of  protoplasm  under  certain  conditions  of  disturbance. 
Pain  is  the  suffering  of  the  living  element  wherever  that  element 
exists.  And  yet  there  must  be  superadded  a  factor  without 
which  our  conception  of  pain  is  incomplete;  that  factor  is  etm- 
scioMsness. 

It  is  not  known  just  where  consciousness  is  located — 
probably  its  zone  occupies  the  entire  cortex  cerebri;  but  just 
there  where  the  nerves  of  common  sensibility  terminate  in  the 
conscious  zone,  is  the  seat  of  pain. 

We  do  not  know  enough  about  the  material  correlatives 
of  conscious  states  in  general  to  warrant  us  in  affirmingthat 
pain  is  not  a  property  of  cortical  cells  whose  ordinary  function, 
under  normal  conditions  of  nutrition  and  stimulation,  is  the 
elaboration  of  sensations,  pleasurable  and  indifferent, 


} 


at 

y. 

n- 
If. 
es 

X- 

te 
ia 

s- 

of 

ys 

a 

at 

!ir 

)  a 
:e. 
int 
mt 
m- 

iist 
he 

res 
lat 
>n, 
he 


—   17   — 

isomeric  states  to  the  other;  then,  having  fallen,  in 
passing  on  and  increasing  the  shock,  they  remain  in- 
capable of  doing  anything  more  until  they  have  re- 
sumed their  previous  isomeric  state." 

But  how  may  we  account  for  the  peculiar  charac- 
ter of  neuralgic  pains  ?  The  pain  of  a  neuralgic  par- 
oxysm is  something  different  from  that  of  abscess  in  an 
otherwise  healthy  individual,  or  the  pain  of  pleurisy. 
The  pain  of  neuralgia  may  be  decomposed  into  a  per- 
manent pain,  and,  at  certain  moments,  aggravations  of 
this  pain,  of  the  nature  of  spontaneous  recrudescences. 
Moreover,  the  neuralgic  suffering  is  attended  wi"' 
painful  irradiations  into  neighboring  nerves  of  the 
same  branch,  and  subsequently  into  other  nerve  trunks 
and  their  branches. 

The  explanation  must  be  sought  in  the  constitu- 
tional state  of  the  subject  whose  neuro-mechanism  is 
in  the  peculiar  condition  of  instability  and  impressi- 
bility before  alluded  to,— responding  to  irritants  in  a 
fitful,  disorderly,  and  excessive  manner;  then,  for  a 
brief  time  becoming  exhausted  till  sufficient  material 
has  been  assimilated  for  another  series  of  discharges. 
The  phenomenon  of  diffusion  and  irradiation  is  ac- 
counted for  by  the  intensity  and  quantity  of  the  mole- 
cular motion  liberated— waves  from  one  set  of  nerves 
being  reflected  upon  other  sets  of  nerves.  According 
to  this  view,  the  phenomenon  is  one  of  peripheral  trans- 
fer—of simple  overflow.  Erb,  however,  has  another 
explanation.  In  these  cases  of  irradiation,  we  have  to 
do  with  a  transfer  of  the  excitation  from  the  central 


'iii&^s^:^^^  ■^tfc.^^Sift***;;?;**:  j«*iiiw.,.^^,«^  vtr-V. , . 


J 


—   i8  — 

cells  to  other  cells  also  central,  but  corresponding  to 
other  nerve  branches,  and  the  sensation  is  referred  to 
the  periphery  of  the  latter  in  virtue  of  the  law  of  eccen- 
tricity.    But  it  would  seem  that  this  explanation,  as 
well  as  that  before  given  of  peripheral  transfer,  is  not 
so  applicable  to  painful  irradiations  as  to  simple  diffus- 
ion of  pain.     Perhaps  the  explanation  given  by  Van- 
lair  may  be  deemed  the  most  satisfactory.     Every 
nerve  of  sensation  exchanges  recurrent  fdaments  with 
the  neighboring  branches.     In  an  algesic  condition, 
the  recurrent  filaments  may  be  spared,  if  the  excita- 
tion does  not  exceed  a  certain  degree  of  intensity.    If, 
however,  the  excitation  becomes  too  vehement,  the 
cells  of  the  recurrent  system  of  nerves  will  take  on 
in  their  turn  the  algesic  state,  to  become  quiet  again 
when  the  hyper-excitation  shall  have  ceased. 

A  similar  use  is  made  of  these  recurrent  filaments 
in  explaining  the  points  douloureaux.     These  filaments 
lose  themselves  suddenly  in  the  tissues  surrounding 
the  nerves  in  the  vicinity  of  a  foramen  of  emergence, 
subcutaneous  tissue,  periosteum,  neurilemma.     If  the 
recurrent  filaments  become  the  seat  of  a  neuralgic 
process,  the  least  pressure  exercised  on  the  tissues  in 
question,  or  even  the  normal  tension  of  the  parenchy- 
mata  or  of  the  blood,  will  always  affect,  in  an  algesic 
sense,  a  part  of  the  fibres  which  form  this  sort  of  ter- 
minal tuft.    The  impression  will  be  transmitted  to  the 
central  cells,  and  these,  by  virtue  of  the  law  of  eccen- 
tricity, will  refer  the  painful  sensation  to  the  periphery, 
to  the  very  point  irritated. 


to 
I  to 
en- 

as 
not 
fus- 
an- 
ery 
vith 
ion, 
;ita- 

If, 

the 

I  on 

gain 

ents 
ents 
ding 
:nce, 

the 
ilgic 
;s  in 
ichy- 
gesic 

ter- 
0  the 
:cen- 
hery, 


i 


CHAPTER  II. 

CLASSIFICATION  OF  THE  NEURALGIAS.* 

The  first  general  division  comprehends  two  great 
classes;  idiopathic  and  symptomatic  neuralgia. 

Idiopathic  or  essential  neuralgia  develops  spon- 
taneously, or  under  the  influence  of  an  excitating 
cause,  but  independently  of  any  general  morbid  state, 
actual  or  pre-existent  or  known  organic  cause. 

Symptomatic  neuralgia  is  dependent  on  the  ex- 
istence of  a  known  organic  cause,  or  generiil  morbid 
state. 

Idiopathic  neuralgias,  from  the  point  of  view  of 
their  cause,  are  not  susceptible  of  any  division. 
Symptomatic  neuralgias  naturally  fall  under  two  cate- 
gories; in  the  first  are  placed  neuralgias  due  to  the 
general  state  (holopathic  neuralgias);  in  the  second, 
those  which  depend  on  a  localized  morbid  state. 

The  general  morbid  state  may  be:  i,  inherent  in 
the  organism  (inherited  or  acquired)  or  2,  the  result 
of  some  poison  introduced  into  the  econrfhiy. 

As  instances  of  neuralgias  dependent  on  a  gen- 
eral morbid  state  apart  from  ordinary  chemical  poi- 
sons, we   have  gouty,  hysterical,  syphilitic,  diphther- 

*I  have  closely  followed  Vanlair's  classification  in  this 
chapter.  Many  of  these  divisions  are  destined  to  be  aban- 
doned as  wider  knowledge  is  gained  of  the  organic  causes  of 
pain. 


■wngur  -irr-vuMjemfr*^'^'^  pyr^Hwen^  IF^.i^f^-^-'-^'^.f^,,- 


TJn^i.;    ,-  ,1,   „TW 


20    — 


itic,  chlorotic,  diabetic  neuralgias,  those  which  follow 
fevers  and  other  acute  diseases,  and  such  as  super- 
vene in  consequence  of  the  suppression  of  an  habitual 
discharge. 

As  examples  of  neuralgia  caused  by  a  poison,  we 
have  lead  (or  painters')  colic,  alcoholic  neuralgia, 
neuralgia  from  abuse  of  tobacco,  or  from  mercury. 

The  localized  morbid  state  may  be  more  or  less 
distant  from  the  seat  of  pain.  Sometimes  the  dis- 
tance is  considerable;  here  the  neuralgia  is  called 
sympathetic,  or  reflex.  Lesions  directly  affecting  the 
nerve  itself,  or  the  tissue  surrounding  it,  do  not  give 
rise  to  true  neuralgia,  but  to  simple  neuralgiform 
pains,  01  pseudo-neuralgia. 

From  the  point  of  view  of  their  seat,  whether 
they  be  idiopathic  or  symptomatic,  neuralgias  are  of 
two  kinds:  i,  neuralgias  of  the  cerebro-spinal  system; 
2,  neuralgias  of  the  ganglionic  system. 

The  pain  may  occupy  the  nerve  trunks  or  their 
peripheral  extremities  (muscles  and  teguments)  or  the 
nerve  centres. 

Hence  *■  we  might  make  another  division  with 
three  clases,  ramicular  neuralgias,  or  common  neural- 
gias, muscular  and  tegumentary  neuralgias,  and  cen- 
tral neuralgias.  The  tegumentary  neuralgias  are 
cutaneous  or  mucous,  and  the  central  neuralgias 
affect  the  cerebro-spinal  axis,  or  the  ganglia  of  the 
sympathetic.  The  visceral  neuralgias  belong  to  the 
latter.  > 


low 
per- 
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the 
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the 


*/\tCiliurA-i_f-w~  .-.;■ 


—  ai  — 

TABLEAU  OF  THE    NEURALGIAS   (FROM    VANLAIR.) 


< 

< 
Pi 

u 

M 

z 


X 
H 

O 


o 

M 
(A 

< 

U 

H 
in 


A.  Ramicu- 
Ur    nerve*, 

or  the 
neuralgias 
properly  lo- 

called. 


I.  N.  Tri- 
facial. 
(Proso- 
palgia.) 


Ophthalmic 
Branch. 


Sup.  max- 
Branch. 


Inferior 

Maxillary 

Branch. 


r 


fN. 


Supra-orbital. 
Prontal-palpcbro- 
natal. 

Bulbar  or  Ciliary, 
— dural. 

Infra-orbital . 

Superior-dental. 

Naio-palatine. 

Anterior  auricular. 

Temporal. 

Buccal. 

Lingual. 

Inferior  dental. 

Mental. 


t.    Facial  nerve  properly  so-called.  The  seventh 
pair. 


3.    (iervesof  the  Cer- 
vical Plexus. 


4.    Nerves  of  Brachial  f  N. 
Plexus  I 


5.  Diaphragmitic 

nerves  (?) 

6.  Dorso-intercostal     ( N. 

Nerves.  < 


fN.    Occipital. 
Mastoid . 

Anterior  cervical. 
Supra-clavicular. 

Circumflex. 

Supra-scapular. 

Ulnar. 

Radial. 

Median, 

Musculo-cutaneous 


7.    Nerves  of  Lumbar  f  N. 
Plexus. 


8.    Nerves   of    Sacral  f  N. 
Plexus. 


Dorsal, 

Intercostal. 

Mammary. 

0 
Lumbar. 
Hypogastric. 
Ileo-lnguinal. 
Scrotalor  labial. 
Crural. 
Obturator. 

Sciatic. 
Anal. 
Perineal. 
Penile. 


9.    Nerves  of  the  Coccygeal  Plexus  (Coccygodl- 
nia.) 


■'t«tit<<iifiu!siiw«iMTO<-W^»<as»jfe 


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< 


33    — 


TABLEAU  OF  THE  NEURALGIAS    (CONTINUED.) 


r 


B.  Muscular  nervei,  or  myalgia. 

C.  Cutaneous  nerves,  or  dermalgia. 

D.  Central  nerv...  I  Cerebralgla. 


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Nerve*  of  the  Pharynx. 
Nerves  of  the  (Esophagus. 
Nerves  of  the  Larynx. 
Neroes  of  the  Lungs. 
Nerves  of  the  Heart. 
Nerves  of  the  Stomach. 
Nerves  of  the  lotestioei. 
Nerves  of  the  Liver. 
Nerves  of  the  Spleen. 
Nerves  of  the  Kidneys. 
Nerves  of  the  Bladder. 
Nerves  of  the  Uterus. 
Nerves  of  the  Ovaries. 
Nerves  of  the  Testicle. 
Nerves  of  the  Vagina. 


."rtHajfl^lft'li  II    iiliiB 


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TABLEAU  OK  THE  NEURALGIAS,    CONTINUED. 
SECOND  CLASS   SYMPTOMATIC   NEURALGIAS. 


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CHAPTER  III. 

THE  CAUSES  OF  NEURALGIA. 

First  among  the  predisposing  causes  is  heredity. 
Since  Morel  and  Moreau  laid  the  foundations  of  the 
doctrine  of  hereditary  neuroses,  all  authorities  have 
recognized  the  influence  of  the  neuropathic  predispo- 
sition in  the  genesis  of  neuralgia.  The  neuralgic  sub- 
ject will  be  often  found  to  have  inherited  in  the  direct 
family  line  the  particular  weakness  of  nerve  organiza- 
tion which  finds  expression  in  the  paroxysmal  attacks 
from  which  he  suffers. 

Nothing,  moreover,  has  been  more  clearly  demon- 
strated than  the  fact  of  the  interchangeability  of  the 
various  neuroses.  The  victim  of  neuralgia  may  have 
had  an  hysterical  or  an  epileptic  mother,  or  an  insane 
father  or  grandfather;  the  neuropathic  tendency  was 
transmitted,  and  circumstances  Iiave  determined  what 
neurosis  should  manifest  itself. 

It  would  appear,  also,  that  the  neuroti.  tcnpera- 
luent  is  largely  akin  to  the  phthisical.  Many  writers 
(and  especially  Anstie)  ha^e  shown  the  interchangea- 
bility of  various  functional  nervous  diseases  with  pul- 
monary consumption.  The  neuropathic  patient  has 
had  a  phthisical  parent;  the  child,  after  suffering  for 
a  series  of  years  from  some  nervous  malady — epilepsy, 
hysteria,  neuralgia— ultimately  dies  of  phthises.     An- 


_    2S    — 

stie's  tables  bring  this  fact  clearly  to  view;  I  have 
myself  seen  frequent  confirmation  of  it.* 

As  for  ax'f,  the  extremes  of  life  have  a  relative 
immunity  from  neuralgia.  Out  of  296  cases,  Valleix 
met  with  but  5  cases  of  neuralgia  in  subjects  between 
seventy  and  eighty  years,  while  there  were  but  2  cases 
in  children  nnder  ten  years.  The  maximum  of  cases 
(68)  was  between  twenty  and  thirty. 

There  are,  however,  more  cases  in  advanced  life 
than  statistics  appear  to  show,  the  number  of  aged 
persons  in  any  community  being  relatively  limited  as 
contrasted  with  that  of  adults.  Anstie  affirms  that 
the  period  of  declining  life  is  preeminently  the  time 
for  severe  and  intractable  neuralgias.  Neuralgia  in 
the  aged  is  associated  with  degenerative  changes  in 
the  arteries,  and  general  mal-nutrition. 

The  middle  period  of  life  is  the  period  of  toil  and 
care.  Men  are  absorbed  in  the  pursuit  of  business 
and  in  the  support  of  their  families;  the  rich  and  the 
idle  are  immersed  in  dissipation,  which,  no  less  surely 
than  exhaustive  toil,  saps  the  vitality;  with  women, 
this  is  the  term  of  child-bearing,  the  rearing  of  fami 
lies,  and  household  drudgery.  Middle  age  brings 
with  it  high  resolves,  great  undertakings,  and  fierce 


♦See  in  this  connection  Chapter  III.  in  Anstie's  book  on 
Neuralgia;  also  Maudsley  "On  the  Pathology  of  the  Mind," 
p.  87  etseg,:  Biandfoid,  "Lectures  on  Insanity."  chipter  on 
Causation. 


i»i««»«ai!iiiFaw»w«aiiig5jj«MiHJUjiiw.'.'ea&-.';i.-- 


—  a6  — 


•> 


■ 


competition;  but  it  also  brings  with  it  disappointed 
hopes,  funut,  and  weariness— all  the  moral  and  physi- 
cal conditions  of  nerve-tire  and  nerve-ache. 

Sex  does  not  appear  to  have  an  important  predis- 
posing influence  on  the  fretjuency  of  neuralgia  in  gen- 
eral. According  to  Putnam,*  if  women  show  a 
stronger  predisposition  than  men  to  certain  forms  of 
neuralgia,  as  to  the  other  neuroses,  it  is  generally 
conceded  that,  whereas  neuralgias  of  the  fifth  and 
occipital  and  of  the  intercostal  nerves  are  met  with 
oftenest  among  them,  the  brachial,  crural  and  sciatic 
neuralgias  more  commonly  occur  among  men,  This, 
he  thinks,  indicates  that  the  neurosal  element  is  of 
greater  weight  in  the  former  group,  the  neuritic  ele- 
ment in  the  latter. 

TAe  sexual  periods  of  life  have  a  recognized  influ- 
ence in  the  production  of  neuralgia.  The  physiologi- 
cal processes  connected  with  the  development  of  the 
reproductive  organs  in  the  male,  with  ovulation  and 
menstruation,  gestation  and  puerperality,  and  the 
menopause  in  the  female,  are  attended  with  the  ex- 
penditure of  enormous  nutritive  and  nervous  energy, 
and  predispose  to  neuralgic  affections.  The  prema- 
ture, excessive,  or  unnatural  exercise  of  these  organs 
and  functions  depresses  the  organism  and  favors  the 
development  of  the  neuropathic  diathesis. 


'Article   Neuralgia  in    Pepper's    System    of    American 
Medicine. 


—  aj  — 

Prnihus  distasfs*  predispose  to  neuralgia  l)y  the 
debility  and  an.x'mia  which  they  occasion;  tlie  same 
may  be  said  of  unhrallhy  hyji^ienic  influtncei  such  at 
bad  air,  and  insufticienl  food.  Cold  and  damp  weather 
has  an  influence;  neuralgias  are  more  prevalent  in 
this  country  in  the  fall  and  spring  months.  General 
disturbances  of  nutrition,  and  especially  those  included 
under  the  names  anx'mia  and  chlorosis,  and  all  cache- 
tic, states,  such  as  cancer,  tuberculosis,  scurvy,  dia- 
betes, may  be  regarded  as  important  conditions  in  the 
etiology  of  this  disease. 

KXCITING    CAUSES. 

It  is  not  always  possible  to  find  for  idiopathic 
neuralgia  any  exciting  cause.  Yet  generally  a  minute 
inquiry  will  bring  out  the  fact  that  there  had  been 
previous  exposure  to  cold  and  wet,  excessive  muscular 
exertion,  inordinate  sensorial  fatigue,  or  some  moral 
shock,  as  the  immediate  antecedent.  Wounds  of  sen- 
sory nerves,  contusions,  gu.i-shol  wounds,  punctures, 
and  other  injuries,  have  caused  most  obstinate  and 
distressing  neuralgias.  Even  comparatively  slight  in- 
juries to  small  sensory  nerves,  as  by  venesection,  a 
subcutaneous  injection,  have  resulted  in  neuralgiform 
pains  or  attacks  of  genuine  neuralgia.  Erb  supposes 
all  these  injuries  to  act  "  either  by  occasioning  inflam- 


*I  have  seen  very  obstinate  neuralgias  follow  typhoid 
fever.  One  very  severe  case  of  gastralgia  that  came  under  my 
observation  was  the  sequel  of  an  exhausting  accouchement. 


■j»^qwfa»g-.-3^„in 


—    28   — 

matory  changes  (neuritis),  or  by  forming  tumors  on 
the  nerves  (traumatic  neuromata,  amongst  which  the 
neuromata  following  amputation  are  the  most  fre- 
quent causes  of  severe  neuralgia),  or  lastly,  purely 
mechanically,  by  pressure  and  laceration  in  conse- 
quence of  the  retention  of  foreign  bodies  in  the 
wound."  * 

.  Dr,  S.  Weir  Mitchell,  in  his  book  "  On  Injuries 
of  the  Nerves,"  has  narrated  many  remarkable  in- 
stances of  neuralgia  starting  from  gun-shot  or  other 
wounds  of  the  nerves,  and  cases  are  on  record  where 
a  fall  on  a  member  has  developed  neuralgia  of  the 
sensory  nerves  of  the  limb.f 

Many  of  these  cases  do  not  seem  to  be  true  neu- 
ralgias, in  fact,  all  traumatic  neuralgias  are  classed  by 
some  authors  (as  Vanlair)  apart,  under  the  head  of 
pseudo-neuralgia s.X  These  neuralgias  have  a  marked 
resemblance  to  ordinary  neuralgias;  sometimes,  how- 
ever, they  are  distinguished  from  the  latter  by  their 


*Zierassen's  Cyclop.,  vol.  xi,  p.  a8. 

t  One  of  the  most  intractable  neuralgias  I  have  ever  wit- 
nessed involved  the  brachial  plexus,  and  was  brought  on  by  a 
fall  on  the  shoulder  in  a  runaway  accident.  Considerable 
atrophy  of  the  muscles  of  the  corresponding  limb  followed.  I 
have  seen,  in  very  sensitive  persons,  neuralgia  succeed  a  hypo- 
dermic injection,  paroxysmal  pain  appearing  at  intervals  daily 
for  several  days. 

%  Vanlair,  Les  Nevralgies,  leurs  formes  et  leur  traUement, 
3d  ed.  (Bruxelles,  1882.) 


JS 

1- 
;r 
re 
le 

1- 

>y 

of 
:d 

V- 

:ir 


it- 

'  a 

>le 

I 

lO- 

ily 

Ht, 


—  29  — 

extraordinary  violence  and  obstinacy.  Sometimes  the 
pain  is  of  a  burning  character,  at  others,  lancinating 
(stabs  or  darts);  it  may  remain  localized  to  the 
region,  or  may  be  of  a  spreading  character.  Trophic 
disturbances  sooner  or  later  follow,  which  affect  par- 
ticularly the  skin;  the  red,  thin,  and  shiny  skin  known 
as  g/ossy  skin,  is  one  of  the  effects  of  traumatic  neu- 
ralgias of  the  extremities. 

Closely  resembling  traumatism  in  its  action  on 
nerves,  are  those  diseases  of  the  periosteum  and  bones 
which  by  mechanically  irritating  and  disordering 
nerves  in  the  neighborhood,  occasion  neuralgia.  The 
fifth  nerve  is  especially  liable  to  such  lesions,  having 
to  pass  through  a  long  narrow  bony  canal,  any 
periosteal  thickening  of  which  cannot  but  seriously 
affect  its  structural  and  functional  integrity.  Syphi- 
litic ostitis  and  periostitis  have  been  reckoned 
among  the  causes;  it  is  doubtful  whether  these  can 
cause  true  neuralgia.  Syphilis  may  produce  neu- 
ralgia by  depressing  the  general  health  and  tone— this 
disease  is,  however,  much  more  likely  to  cause  motor 
affections  (as  paralysis),  than  sensory.  * 

That  cold,  and  especially  damp  cold,  is  an  im- 
portant factor  in  the  production  of  neuralgia,  no  one 
with  much  experience  in  the  various  forms  of  this 
neurosis  will  dispute.  In  fact,  persons  predisposed  to 
neuralgic  affections  are  almost  certain  to  suffer  either 


•Anstie,  lac.  cit.  (Am.  ed.),  p.  175. 


M 


^ag^v9^feja»'.Mgft' 


L 


—  30  — 

a  renewal  or  an  aggravation  of  their  complaints  after 
being  chilled. 

A  special  chapter  will  be  devoted  to  the  reflex 
and  sympathetic  neuralgias  which  are  due  to  organic 
causes  more  or  less  distant  from  the  seat  of  pain,  and 
to  the  toxic  neuralgias  which  result  from  mal-nutrition 
of  the  sensory  nerve  system  by  chronic  poisoning. 

Among  other  causes  of  neuralgia,  must  be  men- 
tioned the  fatty  and  atheromatous  changes  in  the 
tissues  and  arteries  consequent  on  old  age,  overwork 
of  body  and  mind,*  and  diseases  of  the  central  ner- 
vous system,  as  hyperiemia,  inflammation,  and  tumors 
of  the  brain  and  spinal  cord. 


*  Many  severe  cases  of  facial  neuralgia  are  caused  by  eye- 
strain,  as  by  reading  too  long,  and  before  too  bright  a  light. 


»! 


li 


h 


CHAPTER  IV. 

PARTICULAR  FORMS  OF  NEURALGIA. 

I.       FACIAL    NEURALGIA. 

This  disease  has  been  called  prosopalgia,  neu- 
ralgia of  the  fifth,  trigeminal  neuralgia,  and  tic  doulou- 
reux. It  is  one  of  the  most  frequent  of  neuralgias; 
this  is  explained  by  the  relations  of  its  branches  to 
various  important  organs,  the  disturbances  of  which 
may  extend  to  the  nerves  supplying  them,  and  by  the 
fact  that  the  face  is  more  exposed  than  other  parts  of 
the  body  to  cold  and  injurious  influences. 

This  affection  is  generally  unilateral.  As  the 
fifth  nerve  divides  on  emerging  from  the  cranium  into 
three  nerve  trunks,  the  ophthalmic,  the  superior 
maxillary  and  the  inferior  maxillary,  any  one  of  these 
branches  may  be  the  seat  of  the  neuralgia.  Com- 
monly, however,  it  occupies  the  entire  trifacial  nerve. 
As  causes,  the  following  have  been  enumerated: 
"Cold,  deca.ed  teeth,  contusions  and  wounds  of  the 
face,  compression  of  the  nerves  by  foreign  bodies, 
neuromata,  tumors  of  the  petrous  bone,  aneurisms  of 
the  internal  carotid,  tumor  of  the  pons,  fungus  of  the 
dura  mater."  All  the  predisposing  and  exciting 
causes  before  enumerated  may  be  factors  in  the 
genesis  of  this  neuralgia.      Diseases  of  the  nasal  and 


';^»M;^^.SM^(,49LU..^H£ 


.-^^'.■^^.^^:-^..-,^.. 


I! 

lis- 


—  32  — 

frontal  sinuses,  and  fatigue  of  the  eyes,  shock  and 
mental  emotion,  have  been  occasional  causes. 

The  paroxysm  may  come  on  suddenly  or  gradu- 
ally. It  generally  begins  with  a  sensation  of  heat  or 
cold  over  the  affected  parts  with  occasional  violent 
strokes  of  darting  pain,  which  become  more  and 
more  frequent  till  the  attack  is  at  its  height. 

Probably  no  more  atrocious  suffering  is  known. 
"  During  the  attack,  the  patients  utter  loud  outcries, 
toss  about  on  their  beds  and  smite  their  heads;*  the  mus- 
cles of  the  affected  side  of  the  face  are  often  the  seat 
of  rapid  contraction. — convulsive  shocks,  which  have 
gived  to  this  disease  one  of  the  names  by  which  it  is 
known—AV  douloureux.  These  contvnctions  may  be 
limited  to  single  groups  of  muscles,  as  the  zygomaticse, 
or  the  frontal  part  of  the  occipito-frontalis.  The  face 
becomes  turgescent;  there  is  often  photophobia, 
lachrymation,  buzzings  in  the  ears;  then  the  par- 
oxysmal shocks  diminish  in  frequency  and  intensity, 
and  all  becomes  calm;  the  storm  has  passed,  to  be  re- 
newed again  under  t^i  same  form  in  a  time  not  far 
distant. 

According  to  the  branches  affected,  certain  phe- 
nomena present  themselves:  photophobia,  injection  of 
the  eyes,  lachrymation,  transient  amaurosis  in  neural- 
gia of  the  ophthalmic,  odontalgia,  pituitary  secretion 


*  "  In  neuralgias  about  the  head,  the  patient  will  often  be 
seen  to  cringe  and  recede  before  the  plunges  of  pain  as  though 
he  were  receiving  blows."    Buzzard. 


\ 


4fcjtiWii»fcB*iM'to'«Mgtfii*>a*rt'»<M ' 


s 


—  33  — 
in  neuralgia  of  the  superior  maxillary,  painful  deglu- 
tition and  mastication,  exaggerated  salivary  secretion 
in  neuralgia  of  the  inferior  maxillary  nerve."* 

Valleix's  painful  points  are:  i.  supra-orbital,  over 
supra-orbital  foramen;  2,  palpebral;  3,  nasal  (internal 
and  superior  part  of  nose;)  4,  ocular;  5,  infra-orbital 
(infra-orbital  foramen);  6,  molar;  7,  superior  de-ital; 
8,  superior  labial;  9,  palatine;  10,  temporal;  11,  tem- 
poro-maxillary;  13,  mental  (mental  foramen);  14, 
lingual;   15,  inferior  labial. 

Putnam  {/oc.  «/.,  1 232)  makes  three  varieties  of 
facial  neuralgia:   i,  ordinary  facial  neuralgia,  analo- 
gous to  the  neuralgias  of  the  other  superficial  nerves; 
?,    intermittent    supra-orbital    neuralgia,    sometimes 
called   brow-ague,   though   by   no   means  always  of 
malarial  origin;  3,  epileptiform  neuralgia  (tic  doulou- 
reux).     The    first,  or   ordinary   facial   neuralgia,  is 
painful  and  obstinate,  though  not  so  serious  as  tic 
douloureux.     It  is  often  due  to  decayed  teeth,  and 
diseases  of  the  gums  or  of  the  alveolar  process.     The 
second,  or  intermitteit  form,  has  one  variety  which 
bears  a  certain  relationship  to  migraine,  occurs  in  dis- 
tinctly  neuropathic  individuals  and  families,  and  in 
attacks  of  about  the  same  duration  and  periodicity  of 
occurrence.      Another  variety  is  characterized  by  a 
daily  seizure  which  occurs  with  absolute  regularity, 
coming  on  usually  about  nine  in  the  morning,  and 

•  Fit/e  "Clinical  Tiierapeutics,"  p.  76  (foot  note). 


MM«8MWe*)H<teHBii»^lUjB 


—  34  — 
increasing  in  severity  for  an  hour  or  so,  then  persist- 
ing unchanged  till  midday  or  later,  when  it  gradually 
diminishes,  finally  disappearing  in  the  course  of  the 
afternoon.  As  a  rule,  Putnam  says,  is  is  brought  on 
by  catarrh  of  the  frontal  sinuses,  often  following  an 
acute  attack  of  coryza.  'I'his  form  is  greatly  con- 
trolled by  quinine  (15,  20  to  25,  and  even  30  grains) 
four  hours  before  the  attack.  The  epileptiform  vari- 
ety (tic  douloureux)  is  characterized  by  the  sudden- 
ness of  its  onset,  and  the  severity  of  its  paroxysmal 
pain.  The  path  pursued  by  the  darts  of  pain  is  gen- 
erally in  the  direction  of  the  nerve-tracks.  According 
to  Putnam's  view  above  given,  the  name  tic  doulour- 
eux is  only  applicable  to  the  disease  when  it  appears 
in  its  more  painful  character. 

Treatment.— On\y  the  surgical  treatment  will  be 
here  mentioned.  The  medicinal  treatment  will  be  dis- 
cussed in  the  chapter  devoted  to  general  therapeutics. 

In  185 1  Dr.  J.  M.  Carnochan  operated  in  the  first 
case  for  complete  resection  of  the  second  branch  of 
the  fifth  pair  from  the  foramen  rotundum  to  the  infra- 
orbital foramen—with  the  removal  of  Meckel's  gan- 
glion—with complete  success.  Simple  subcutaneous 
section  of  the  infra-orbital  nerve  in  the  cheek  had 
been  often  done  before  that  time,  but  with  no  very 
encouraging  results;  in  fact,  the  relief  coming  from 
the  operation  was  very  temporary. 

The  operation  is  a  bold  one,  and  involves  trephin- 
ing the  antrum. 


i 


—  35  — 
Dr.  Robert  Abbe,  of  New  York,  has  lately  pub- 
lished in  the  New  York  Medical  Journal  reports  of  a 
series  of  cases  in  which  he  has  performed  Carnochan's 
operation  with  brilliant  success.* 

II.     MIGRAINE,  ITS    PATHOLOGY    AND    TREATMENT.f 

According  to  Anstie,  migraine  (hemicrania)  is  a 
variety  of  neuralgia  of  the  ophthalmic  division  of  the 
fifth  nerve.  He  remarks  that  the  attacks  of  migraine 
often  interchange  with  neuralgia  seizures;  that  they 
often  begin  with  pain  distinctly  located  in  the"  supra- 
orbital nerve,  as  the  result  of  exposure  to  cold  or 
other  of  the  causes  of  ordinary  neuralgia.  This  view 
is  favored  by  Senkler  in  "  Pepper's  System  of  Medi- 
cine." 

Romberg  regarded  migraine  as  a  neuralgia  of  the 
cerebrum,  but  Hesse  observes  that  the  symptoms  of 
this  neurosis  are  equally  compatible  with  its  location 
in  the  branches  of  the  fifth  distributed  to  the  meninges 
and  bones  of  the  cranium. 

There  is,  however,  much  to  be  said  in  defence  of 
the  view  that  migraine  is  primarily  a  neurosis  of  the 
sympathetic  nerve.  According  to  Du  Bois-Reymond, 
the  phenomena  of  migraine  are  best  explained  by  the 


•  Vide  New  York  Medical  Journal,  Aug.  3d,  1889. 

f  In  this  section,  as  in  one  or  two  other  instances  {vide 
angina  pectoris),  the  writer  has  availed  himself  of  articles  of  his 
own  which  have  appeared  in  the  Boston  Medital  and  Surgical 
Journal  and  Medical  Age. 


-  36  - 
supposition  that  there  is  abnormal  excitation  of  the 
sympathetic  on  the  affected  side,  and  he  emphasizes 
in  this  connection  the  retraction  of  the  temporal  artery, 
the  pallor  of  the  countenance,  the  dilatation  of  the 
pupil;  all  of  which  are  due  to  tonic  contraction  of  the 
vascular  and  oculo-pupillary  muscles. 

But,  as  Jaccoud  remarks,  the  constancy  of  these 
phenomena  has  not  been  established,  and  Moellendorff 
afterwards  maintained  a  directly  contrary  view,  to  wit, 
that  the  symptoms  of  hemicrania  depend  on  the  unilat- 
eral relaxation  of  the  vessels  of  the  head,  from  want  of 
energy  of  the  vaso-motor  nerves.  Eulenburg*  adopts 
an  intermediate  theory,  affirming  that  a  certain  class 
of  cases  is  undoubtedly  vasomotor  in  its  origin.  He 
describes  two  types  of  m'^jraine:  the  sympathetico- 
tonic  or  angiospastic,  and  the  angio-paralytic  or 
neuro-paralytic  forms.  In  the  one,  the  face  is  pale 
and  sunken;  in  the  other,  it  is  hot,  turgid  and  flushed 
during  the  height  of  the  attack.  In  the  one,  the  pupil 
is  dilated  and  the  temporal  artery  appears  as  a  hard 
cord;  m  the  other,  the  pupil  is  contracted,  and  the 
temporal  artery  is  swollen  and  throbs  with  increased 
force.  In  the  one,  the  eyes  are  pale  and  sunken;  in 
the  other,  they  are  suffused  and  prominent. 

Jaccoud  reconciles  the  pathological  differences 
above  mentioned  by  ipssuming  that  there  cannot  be 
two  vascular  conditions  so  contradictory,  as  the  sub- 


i 


•Ziemssen's  Cytlop.  Art.  Hemicrania. 


--  '^Ji»*^»<WH>ti-ica**'i^ 


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,!W>MMLJWipW»aMNl 


—  37  — 
stratum  of  migraine.  If,  he  says,  clinicians  have  wit- 
nessed opposite  phenomena,  it  is  simply  because  they 
observed  at  different  periods;  in  other  words,  the 
paroxysm  of  migraine  is  constituted  by  an  abnormal 
excitation  of  the  sympathetic  followed  by  a  paralysis 
by  exhaustion,  which  marks  the  decline  and  the  ter- 
mination of  the  paroxysm.  The  contraction  of  the 
vessels  during  the  onset  and  the  active  period  of  the 
attack  explains  why  the  pain  is  exaggerated  at  each 
pulsation  of  the  artery;  as  for  the  origin  of  this  pain, 
it  may  be  attributed  to  the  vascular  cramp  itself,  which 
compresses  the  nerve  filaments  contained  in  the  un- 
striped  muscles.* 

Hemicrania  is  a  disease  from  which  no  station  or 
condition  of  life  is  exempt.  Rich  and  poor,  the  man 
of  ease  and  the  fashionable  lady,  the  mill-operative 
and  the  kitchen  drudge,  are  alike  subject  to  migraine. 
Among  the  factors  in  its  production,  hereditary  pre- 
dispostion  is  the  most  potent.  The  disease  follows 
the  female  line,  being  usually  inherited  from  the 
mother  only,  and  by  the  daughters  only  (Eulenburg). 
When  there  is  a  strong  hereditary  tendency,  girls  of 
quite  a  young  age  may  be  attacked  by  migraine, 
Eulenburg  has  known  girls  of  four  or  five  years  to  be 
sufferers. 

In  half  the  women  affected  with  migraine,  the  at- 
tacks occur  at  the  menstrual  period  or  immediately 


^Jaccoud:  Path.  Interne,  t.  i,  p.  478. 


1     .' 


='!'- 


_  38  - 

after.  In  other  cases,  the  attacks  are  due  to  mental 
excitement,  after  attendance  at  a  party,  at  a  theatre, 
etc.  Sometimes  the  attack  is  provoked  by  reading 
and  study;  some  persons  have  hemicrania  from  read- 
ing by  artificial  light.  The  attacks  sometimes  appear 
to  originate  in  indigestion. 

It  is  in  this  form  of  neuralgia  that  the  recently 
discovered  analgesics,  antipyrin,  acetanilide,  phena- 
cetin,  exalgin,  seem  to  do  the  most  good.  Here  the 
triumph  of  guarana  and  caffein  is  often  seen. 
When  the  attack  can  be  traced  to  the  stomach,  ipecac- 
uanha in  one-fourth  grain  doses  every  hour  has  been 
commended,  also  rhubarb  and  soda,  or  some  of  the 
effervescing  aperients. 

In  the  angio-spastic  variety,  nitrite  of  amyl  in- 
halations, and  nitro-glycerin  by  mouth,  have  been 
beneficial.  In  the  angio-paralytic  form,  ergot  has 
been  found  useful. 

Senkler  speaks  favorably  of  bromide  of  lithium, 
fifteen  grains  every  hour  for  two  or  three  doses.  The 
effervescent  bromide  of  caffein,  or  bromo-pyrin,  is  a 
good  preparation.  Seguin's  favorite  treatment  is 
cannabis  indica,  one-fourth  grain  doses  of  the  alco- 
holic extract  three  times  a  day,  to  be  continued  for 
weeks  and  even  months.  Aconitia  (one  two-hun- 
dredth grain)  and  gelsemium  have  been  praised;  the 
former  is,  perhaps,  one  of  the  most  certain  remedies 
in  the  angio-spastic  variety.  Malarious  forms  are 
speedily  benefited  by  large  doses  of  quinine.    Always^ 


—  39  — 
as  prophylactic   treatment,  arsenic   and  cod-liver  oil 
are  indicated. 

Anstie  and  Eulenbiiry  think  well  of  galvanism 
to  the  head  and  sympathetic.  Firm  pressure  on  the 
head  and  compression  of  the  carotids  sometimes  give 
relief;  the  same  may  be  said  of  sinapisms  to  the  nape 
of  the  neck,  and  the  application  of  a  hot-water  bag  to 
the  back  of  the  head. 

After  all,  resort  must  sometimes  be  had  to  hypo- 
dermic morphia  in  the  atrocious  suffering  of  mi- 
graine. 

Migraine,  says  Lasagne  (Etudes  Medicales,  vol.  II.,  p. 
331),  is  a  disease  of  paroxysms;  a  man  who  suffers  from  con- 
tinuous lieadaclie  is  not  migrainous.  The  attaclcs  do  not  repeat 
themselves  at  periods  that  can  be  mathemeticaliy  calculated. 
*****  Ordinarily,  the  attaclcs  do  not  recur 
oftener  than  once  a  week.  On  the  other  hand,  he  who  has 
only  one  or  two  attacks  a  year,  cannot  be  said  to  be  a  victim  of 
true  migraine.      «      ♦      * 

The  duration  of  the  attack  also  obeys  positive  laws.  Any 
attack  of  cephalalgia  which  lasts  less  than  six  hours  and  more 
than  forty-eight  hours,  cannot  properly  be  called  migraine. 
Typical  migraine  appears  in  the  morning.  Afier  certain  pro- 
dromes: physical  and  mental  atony  with  diminution  of  appetite, 
pallor,  faiigue,  the  headache  begins  with  a  diffused  sensation 
of  cranial  tension,  sometimes  by  a  pain  in  one  spot,  which 
spreads  over  the  cranium  and  face  of  the  affected  side,  never 
limiting  itself  to  a  nerve  tract. 

Topographically,  migraine  is  hemicranial,  occipital,  syn- 
cipital,  or  diffuse;  in  the  first  case  it  has  its  maximum  of  inten- 
sity  in  the  orbit,  in  the  infra-orbital  and  temporal  regions, 
never  fixing  itself  below  the  infra-orbital  line;  at  the  most  there 


—  46  — 

ii  A  vague  tentatlon  of  weight  and  twelllng  of  the  face  and  a 
little  aching  of  the  teeth.  The  occipital  form  la  the  moat  pain- 
ful, and  is  rarely  hemlcranial;  the  syncipltal,  never. 

Migraine  is  exceptionally  diffuse  at  first;  starting  from 
one  or  more  points,  it  spreads  with  rapidity  to  the  entire  cran- 
ial  surface,  without  having  everywhere  an  equal  intensity.  Pa- 
tients  affirm  that  the  skin  seems  to  be  detached,  as  though  thev 
were  being  scalped.  Sometimes,  however,  the  integument 
seems  to  adhere  to  the  sicull  by  a  violent  retraction  the  patients 
complain  of  being  tortured  by  a  leaden  cap,  or  by  an  iron  band. 
Intolerable  as  the  pain  is,  it  is  rather  contunding  than  lancina- 
ting, and  seems  to  the  patient  rather  fxira  than  intra  cranial. 

In  proportion  as  the  paroxysm  advances  towards  its 
acme,  the  sufferings  become  ordinarily  more  confused,  proba- 
bly by  reason  of  the  general  malaise  which  becomes  more  pro- 
nounced; sometimes,  however,  the  pains  change  their  place, 
redoubling  their  intensity.  This  sudden  migration  of  the  pain 
during  the  attacit  is  a  remarkable  fact  which  differentiates  mi- 
graine from  the  ordinary  neuralgias;  sometimes,  for  instance, 
the  pain  suddenly  shifts  from  the  left  to  the  right  side,  or  vice 
versa. 

To  the  pericranial  sufferings  are  soon  conjoined  certain 
ailments  connected  with  the  stomach  which  have  given  to  mi- 
graine one  of  its  names,  sick-htadache.  There  is  nausea, 
retching,  and  vomiting  during  the  attack;  these  symptoms  pre- 
dominate in  the  stationnry  period  and  then  sometimes  cut  short 
the  att&ck,  though  at  the  onset  vomiting  does  not  relieve. 

It  may  be  affirmed  that  no  attack  of  headache  not  accom- 
panied by  gastric  complications  is  true  migraine. 

In  the  third  period  the  violent  pain  is  decreased,  and  the 
nausea  much  less  pronounced.  The  head  becomes  heavy;  it 
seems  at  times  as  if  it  were  enormously  swollen;  the  pain 
through  the  eyes  is  more  pronounced,  though  vision  may  be 
unaffected.     The  first  manifestations  of  a  cerebral  kind  are  in- 


■  I     ■■■niiiiiiii»,i*ft'>ir'itii«w,'i-ii«r)n,7.riii  rr^irii— Tfw— .^  —  ..^^^■^,  -.»>.m..uc* 


—  4t  — 

tcllectual  torpor  with  absence  of  Ideu,  or  a  lub-dellrium 
•imilar  to  that  of  dreami,  though  the  patient  can  still  control 
himself  The  necessity  of  sleep  is  now  felt,  and  the  patient 
gladly  yields  to  it;  a  delicious  slumber  closes  the  attack;  the 
patient  wakes  with  a  feeling  of  prostration,  though  free  from 
pain;  he  is  not  himself  again  until  he  has  taken  food. 

If  the  attack,  when  left  to  itself  and  pursuing  its  course 
io  silence  and  darkness — the  favorite  environment  of  the  mi- 
grainous— accomplishes  thus  its  regular  evolution,  it  may  be 
suddenly  interrupted  by  adventitious  modifying  circumstances. 
Many  a  sufferer  from  migraine  has  experienced  sudden  deliv- 
erance from  his  attack  under  the  influence  of  a  strong  emotion, 
a  fright,  or  a  piece  of  unexpected  good  news. 

[It  may  be  added  that  the  same  eHect  may  be  produced  by 
full  doses  of  some  of  the  modern  analgesics,  and  especially  antl- 
pyrine,  phenacetin,  and  caffeine.  | 


III. 


CERVICO-OCCIPITAL     NKURALUIA. 


This  is  an  uncommon  form  of  neuralgia,  affecting 
the  sensory  nerves  of  the  occipital  region,  neck  and 
nape  of  the  neck;  the  pain  is  located  in  the  first  four 
cervical  nerves. 

The  causes  do  not  differ  from  those  which  pro- 
duce facial  neuralgia.  According  to  the  observations 
of  Valleix,  this  form  of  neuralgia  is  most  generally 
due  to  prolonged  exposure  to  cold,  as  sitting  in  a 
draught.  Neuritis  and  congestion  of  the  neurilemma 
are  suggested  as  probable  causes.  Disease^  of  the 
vertebrae  also  appear  to  induce  this  form  of  neuralgia, 
by  pressing  on  the  veins  as  they  pass  out  of  the  verte- 
bral canal,  and  swollen  lymphatic  glands  deep  in  the 


—  42  — 
neck  by  pressing  on  the  cervical  plexus  and  occipitalis 
major  (Niemeyer). 

There  are  painful  points  over  the  first  two  verte- 
bra, at  the  point  of  exit  of  the  great  occipital  nerve 
from  the  complexus,  over  the  mastoid  process,  near 
the  parietal  protuberance,  and  in  the  auricle. 

As  the  tendency  of  this  neuralgia  is  to  spread  to 
the  lower  part  of  the  face,  it  sometimes  becomes,  as 
Valleix  observes,  indistinguishable  from  neuralgias  of 
the  third  division  of  the  trigeminus. 

In  the  treatment  of  this  affection,  neurotomy  has 
been  tried,  but  with  only  partial  success.  Anstie  has 
derived  marked  benefit  from  blistering. 

IV.       CERVICO-BRACHIAL     NEURALGIA. 

By  cervico- brachial  neuralgia  is  meant  neuralgia 
having  its  seat  in  the  four  lower  cervical  vertebrte  and 
in  the  first  dorsal  (the  brachial  plexus).  These  are 
neuralgias  of  the  shoulder,  arm,  forearm,  and  hand, 
and  they  are  often  very  severe  and  obstinate. 

The  causes  are  oftener  extrinsic  (from  material 
lesion)  than  in  any  other  form  of  neuralgia.  Injuries 
of  the  brachial  plexus  by  cutting  instruments,  gun- 
shot wounds,  contusions,  neuromata,  swollen  lym- 
phatic glands,  or  aneurismal  tumors  in  the  axilla,  peri- 
ostitis, tubercle  or  cancer  of  the  vertebrae  causing 
pressure  on  the  nerves  at  their  foramen  of  emergence, 
have  been  enumerated  as  perceptible  causes.  Attacks 
of  this  neuralgia  have  been   referred  to  immoderate 


^i'. 


»H«1*»*.J!--^^'*J-W 


—  43  — 
exercise  of  the  muscles  of  the  forearm  and  hand,  as  in 
playing  on  the  piano,  in  sewing,  and  in  knitting. 

The  pain  is  paroxysmal,  of  regular  or  irregular 
type,  and  is  characterized  by  lancinations  in  various 
directions,  which  make  themselves  felt  especially  in 
the  terminal  expansion  of  the  nerves.  The  most 
common  seat  of  cervico-brachial  neuralgia,  according 
to  Anstie,  is  the  ulnar  nerve,  though  the  pain,  when 
intense,  always  spreads  to  the  other  sensory  nerves  of 
the  brachial  plexus.  In  a  very  obstinate  case  to 
which  I  have  before  referred,  the  principal  focus  of 
the  pain  was  the  shoulder. 

In  another  case,  of  which  I  have  notes,  the  neu- 
ralgia was  brought  on  by  a  contusion   (a  fall   from  a 
carriage).     For  thirteen  years,  this  patient  (an  elderly 
lady)  was  a  sufferer  from  neuralgia,  affecting  chiefly 
the  ulnar  nerve,  the  inner  part  of  the  forearm  and 
little  and  ring  fingers  being  chiefly  affected.      During 
the  severe  paroxysms  of  pain   (which  were  frequent) 
the'  fingers  were  contractured  in  a  semi-flexed  condi- 
tion.      The    forearm    and   hand   were   permanently 
swollen  and  somewhat  livid,  the  outer  fingers  were 
often  numb  and  cold.     Prickly  sensations  were  com- 
mon.     During    the    painful   crises,   all   the   sensory 
nerves  of  the  fingers  seemed  affected;  the  pain  being 
principally  in  the  terminal  extremities  of  the  nerves. 
During  the  intervals  of  the  attacks,  there  was  always 
an  aching  pain  along  the  ulnar  side  of  the  forearm.    In 
damp,  chilly  weather,  the  attacks  were  generally  worse. 


,^Biaiiigg»<p(iifeini«aaaigiBfc' 


—  44  — 

This  case  seemed  to  me  to  be  a  fairly  typical 
one.  Antipyrine  in  lo  grain  doses,  arsenic,  iron,  cod- 
liver  oil,  and  opiates  were  all  tried  in  this  case.  Anti- 
pyrine gave  much  relief  the  last  two  years  of  this  pa- 
tient's life,  and  frequently  stayed  the  paroxysms,  but 
morphine  was  often  necessary.  A  proprietary  pre- 
paration of  opium  called  svapnia  in  \  grain  doses  was 
resorted  to  with  benefit  at  times,  and  seemed  to  have 
less  baneful  after-effects  than  morphine. 

In  cervico-brachial  neuralgia,  neurectomy  of  the 
affected  nerve  has  sometimes  been  followed  by  a  per- 
manent cure. 


V.      INTERCOSTAL     NEURALGIA. 

Intercostal  neuralgia  is  neuralgia  affecting  the 
sensory  branches  of  the  dorsal  nerves.  These  nerves 
— twelve  in  number — divide  after  their  emergence 
from  the  intervertebral  foramen,  mto  an  anterior  and 
a  posterior  branch;  the  anterior  cords  are  the  inter- 
costal nerves,  the  posterior  branches  are  distributed 
to  the  muscles  and  skin  of  the  bdck. 

The  intercostal  nerves  run  along  in  the  inter- 
costal space,  at  first  resting  on  the  external  intercostal 
muscles,  then  lying  between  the  muscles;  beyond  the 
middle  of  thf  rb  they  enter  the  substance  of  the  in- 
ternal intercostal  muscle,  and  reach  the  inner  surface, 
being  in  contact  ivith  the  pleura;  at  the  anterior  ex- 
tremity of  the  intercostal  space  they  pierce  the  mus- 
c'es  and  are  distributed  to  the  integument.     Midway 


-^saujwur&iu!-'-' 


.  .^^fc^itNHuaiiWjiisei«iu0v«!^iS< 


•?afea»H'<»>«J'»w^*^i'*''^g^'^'-^^g'"*^-^''J**^"^'''*'''***'''*'^^^*^'- 


■jgiemiamimoiitsaisi:-- 


—  45  — 
between  the  vertebral  column  and  sternum,  each 
intercostal  nerve  gives  off  a  lateral  cutaneous  branch, 
which  pierces  the  external  intercostal  muscle  and 
divides  into  twigs  for  the  supply  of  the  skin  of  the  side 
of  the  thorax.  The  six  lower  intercostal  nerves  con- 
stitute the  anterior  cutaneous  nerves  of  the  abdomen. 

The  points  douloureux  are  three  in  number: 
one  posterior,  by  the  side  of  the  spinous  processes, 
over  the  point  of  emergence  of  the  nerves;  one 
median,  over  the  point  where  the  lateral  cutaneous 
branch  perforates  the  muscles;  an  anterior,  situated  a 
little  outside  the  sternum,  or  at  the  epigastrium,  ex- 
ternally to  the  median  line  at  the  origin  of  the  ante- 
rior perforating  branch.  These  circumscribed  spots 
are  generally  very  sensitive  to  touch  or  pressure. 

Intercostal  neuralgia  is  generally  unilateral  and 
seated  on  the  left  side.  It  is  more  common  in 
females  than  in  males,  and  generally  affects  several 
of  the  intercostal  nerves  at  the  same  time. 

The  causes  are  multiple:  impression  of  cold; 
contusion  of  the  thorax;  neuritis;  neuroma;  lesion 
of  neighboring  organs,  as  the  lungs,  pleura,  and  ver- 
tebral column;  congestion  and  dilatation  of  the  intra- 
vertebral  venous  plexuses  or  intercostal  veins.  Inter- 
costal neuralgia  is  a  very  frequent,  though  not  con- 
stant, accompaniment  of  herpes  zoster,  and  has  been 
known  in  a  very  obsimate  form  to  follow  attacks  of 
pleurisy.  It  may  be  reflex,  and  accompany  catarrh  of 
the  digestive   tube   and   diseases  of  the   uterus  or 


i 


' 


•4 


_  46  - 

ovaries.  It  is  observed  in  hysteria,  chlorosis,  anaemia, 
malaria,  lead  poisoning,  syphilis,  and  rheumatism. 
Michel  Peter  defines  the  pain  of  pneumonia  as  a 
pleuritic  pain,  and  regards  the  latter  as  an  intercostal 

neuralgia.* 

Dujardin-Beaumetz  regards  the  pams  m  the  side 
observed  in  phthisical  patients  at  the  apex  of  the 
lungs  as  neuritis  from  inflammation  of  the  lungs  and 
pleura.  In  tuberculous  neuritis  it  is  the  first,  second, 
and  sometimes  third  intercostal  spaces  that  are  the 
seat  of  the  pain.  In  anaemic  neuralgias  it  is  the 
fourth,  fifth,  and  sometimes  sixth  intercostal  spaces 
on  the  left  side,  and  the  pain  is  most  severe  on  a  level 
with  the  fourth  dorsal  vertebra. 

Continuous  pain  is  the  predominant  symptomatic 
element,  presenting  itself  under  the  form  of  a  con- 
strictive tension  half  girdling  the  thorax  and  exagger- 
ated by  movements,  especially  those  of  respiration 
(Jaccoud).  Along  with  this  dull  continuous  pain, 
there  are  shootings  along  the  course  of  the  intercostal 
nerves.  Real  paroxysmal  accessions  are  less  common 
than  in  other  forms  of  neuralgia,  yet  they  now  and 

then  occur. 

Double  intercostal  neuralgia  (which  is  very  rare) 
would,  according  to  Jaccoud,  lead  one  to  suspect  the 
existence  of  an  intra-thoracic  tumor,  or  a  chronic  dis- 
ease  of  the  spinal  cord  or  its  membranes. 


•  Clinical  TherapeuUcs.  p.  74- 


'ff^f.i^meamiHtf^'t 


li,it^,^gii^jiiMM>trm!mimSllii*J>s:n-dMmmfFin9'!VBmm»*'' 


IC 

1- 
r- 
•n 

n, 
al 
>n 
id 

e) 

lie 
is- 


—  47  — 

Intercostal  neuralgia  is  liable  to  be  confounded 
with  pleurodynia  or  rheumatism  of  the  thoracic  mus- 
cles. In  the  latter  affection  the  pain  is  more  diffused 
than  in  intercostal  neuralgia,  is  seated  in  certain  mus- 
cles, is  aggravated  by  certain  movements,  and  gets 
well  in  a  few  days;  moreover,  there  is  absence  of  the 
painful  points. 

With  regard  to  the  treatment,  the  general  prin- 
ciples laid  down  in  a  subsequent  chapter  are  here  ap- 
plicable. All  authorities  speak  favorably  of  counter 
irritation  to  the  skin;  Valleix  and  Erb  especially  com- 
mend flying  blisters,  applied  in  succession  over  the 
painful  points.  Erlenmeyer  recommends  repeated 
cauterization  of  the  skin  with  nitrate  of  silver.  Fara- 
dization with  the  metallic  brush  has  seemed  some- 
times to  do  good.  In  one  bad  case  that  came  under 
my  observation,  firm  pressure  over  the  painful  foci 
with  the  bare  hand  gave  great  relief  during  the  at- 
tacks. Chloroform  and  menthol  liniments  and  the 
local  application  of  cocaine  solutions  confer  but  little 
benefit.  Hypodermic  injections  of  chloroform  or 
antipyrine  may  be  tried;  these  failing,  the  resort,  as 
usual,  must  be  to  morphine,  by  mouth  or  subcutane- 
ously. 

VI.      MASTODVNIA — IRRITABLE    BREAST. 

Women  about  the  period  of  puberty  or  from  then 
to  the  thirtieth  year,  often,  without  any  perceptible 
cause,  become  sensitive  to  the  slightest  touch  at  one 


-BE_; 


-48- 

or  more  points  over  the  mammary  gland.  Severe 
pain  liice  tic  douloureux,  occasionally  shoots  out  to- 
ward the  shoulder,  axilla,  or  hip. 

The  disease  sometimes  develops  in  connection 
with  pregnancy  or  lactation.  Now  and  then  small 
neuromata  or  painful  tumors  of  the  nerves  of  the 
mammary  glands  appear  to  be  the  starting  points  of 
the  neuralgia;  these  consist  of  connective  tissue,  not 
of  glandular  substance. 

Mastodynia  is  sometimes  very  obstinate.  Cooper 
recommends  a  belladonna  plaster;  Romberg,  pills  of 
ext.  conii,  ext.  papaver  (aa  gr.  ij),  ext.  stramonii  (^  to 
J  gr.),  to  be  taken  according  to  indications. 

VIl.       LUMBO-AHDOMINAL    NEURALGIA. 

Neuralgia  of  the  lumbar  plexus  is  generally  situ- 
ated on  the  left  side.  Its  causes  are  various:  impres- 
sion of  cold,  contusion,  alteration  or  compression  of 
nerves  by  bony  tumors  or  other  tumors  in  the  vicinity. 
It  may  be  provoked  by  a  mordid  state  of  the  genital 
organs,  testicle,  uterus,  and  its  annexes,  and  co-exist 
with  neuralgia  of  the  neck  of  the  womb.  It  may  oc- 
cupy all  the  branches  of  the  plexus,  or  several  of  them, 
or  each  of  the  following  branches:  i.  The  abdominal 
branches  which  furnish  the  ilio-scrotal  nerve;  2.  The 
internal  inguinal  branches;  3.  The  external  branch 
which  furnishes  the  scrotal  or  labial  nerves. 

The  pain,  as  in  all  other  neuralgias,  is  permanent, 
dull,  or  contusive,  or  is  paroxysmal.     The  attacks  are 


■ 


i?Wi,y. 


—  49  — 
spontaneous,  or  provoked  by  walking,  sudden  move- 
ments, pressure  over  the  nerve,  etc.,  and  remain 
limited  to  the  hones,  the  flank,  and  the  inferior  part 
of  the  hypogastrium,  or  are  propagated  to  the  groin 
or  the  testicle,  or  labia  majora,  according  as  the  scrotal, 
testicular,  labial  branch,  etc,  is  affected.  Irritable 
testicle,  according  to  Sir  Astley  Cooper,  is  ileo-scrotal 
neuralgia.* 

The  treatment  does  not  differ  essentially  from 
that  of  dorso-intercostal  neuralgia. 

CocLVDVNrA. — This  is  neuralgic  pain  having  its 
seat  in  the  region  of  the  coccyx.  Women  are  more 
subject  to  it  than  men.  It  is  felt  particularly  in  sitting 
and  during  defecation.  Buzzard  regards  it  as  neural- 
gia of  the  coccygeal  plexus.  The  treatment  consists 
either  in  subcutaneous  division  of  the  muscles  and 
fibrous  structures  attached  to  the  coccyx,  or  in  extirpa- 
tion of  the  coccyx. t 


VIII.       NEURALGIA    OF     THK    SCIATIC    NKRVE. 

Neuralgia  may  attack  any  of  the  sensory  branches 
of  the  sacral  plexus,  and  the  term  sciatica  is  often 
used  to  designate  neuralgia  of  that  plexus.  Want  of 
space  obliges  me  to  restrict  the  signification  of  the 
word  (in  accordance  with  its  common  acceptation) 
to  neuralgia  of  the  great  sciatic  nerve. 


*  Reprinted  from  Clinical  Therapeutics,  note  3,  p.  73, 
t  Art.  Neuralgia  in  Quoin's  Dictionary  of  Medicine. 


4  MM 


.*»TaHB^?a®®2aiiBRse»^58^B«sa«sae^^s^ssfrs^ssKte 


7^Sf^^4^^iS^Mx!^S^^i!^^^t^'TT^i^ 


^zi-'^v'^xm 


—  50  — 

Cotugno,  an  Italian  physician,  more  than  a  cen- 
tury and  a  quarter  ago,  gave  the  first  magisterial 
description  of  sciatica;  his  pathology  has  been  out- 
grown, for  he  attributed  the  disease,  in  great  part,  to 
dropsy  of  the  nerve  sheath,  and  compression  of  the 
nerve  substance. 

Valleix  at  a  later  day,  relegated  sciatica  to  the 
rank  of  functional  neuroses  under  the  name  oifemoro- 
popliteal  neuralgia. 

The  search  for  points  douloureux,  as  usual,  pre- 
occupies Valleix.  His  painful  points  are  as  follows: 
I.  A  lumbar  point  immediately  above  the  sacrum;  2. 
A  sacro-iliac  point  on  a  level  with  the  sacro-iliac 
articulation,  in  front  of  the  posterior  superior  spine 
of  the  ilium;  3.  Iliac,  over  the  crest  of  the  ilium;  4. 
Gluteal,  at  the  top  of  the  great  sciatic  notch;  5. 
Trochanteric,  upper  border  of  the  great  trochanter;  6. 
Femoral  points  superior,  middle,  and  inferior,  over 
the  origin  of  the  principal  nerves  given  off  from  the 
sciatic;  7.  Popliteal,  over  the  popliteal  space;  8. 
Patellar,  over  the  patella;  9.  Peroneo-tibial,  over  the 
upper  articulation  of  the  tibia  and  fibula;  10.  Pero- 
neal, about  the  neck  of  the  fibula;  11.  Malleolar,  at 
the  posterior  and  inferior  part  of  the  external  malleo- 
lus; 12.  Dorsum  of  the  foot  and  plantar  region. 

In  other  words,  according  to  Valleix,  sciatica 
obeys  the  law  according  to  which  the  pains  are  con- 
centrated: I,  at  the  point  of  emergence  of  the  nerve 
trunk;  2,  in  the  points  where  a  nerve  filament  traverses 


-^ 


!n- 
ial 

ut- 
to 
he 

he 
ra- 
re- 
vs: 

2. 

iac 

ine 

4. 

6. 
i^er 
;he 

8. 
the 
ro- 

at 

BO- 

ica 
3n- 
rve 
ses 


—  SI  — 
the  muscle  to  approach  the  skin  to  which  it  is  dis- 
tributed; 3,  in  the  points  where  the  terminal  branches 
lose  themselves  in  the  teguments.*  Lasegue  has 
pointed  out  that  Valleix,  in  calling  attention  to  pain 
and  especially  paroxysmal  pain,  as  the  principal  dis- 
tinguishing element,  and  overlooking  the  fact  of  a 
morbid  organic  process  with  its  periods,  its  acuteness, 
and  its  chronicity,  has  given  a  picture  which  is  little 
in  accordance  with  clinical  facts  as  they  ordinarily 
present  themselves  to  the  practitioner.  He  regards 
sciatica  as  an  organic  disease,  due  to  neuritis,  or  some 
degenerative  alteration  of  the  nerve. 

It  cannot  however,  be  said  that  the  relatively  few 
post-mortem  examinations  that  have  been  made  of 
sciatic  patients  have  revealed  that  constancy  of  morbid 
changes  which  would  bear  out  La^cgue's  view.  Erb 
regards  the  anatomical  changes  as  oimply  accidental 
accompaniments  of  the  disease.  It  is,  however,  true 
that  in  the  experience  of  many  practitioners,  as  in  that 
of  Lasegue, t  the  disease  has  not  been  r,o  much  char- 
acterized by  lancinating,  ingravesce.it  pangs,  as  by  a 
constant  dull  pain  aggravated  by  pressure  and  motion 
seated  in  some  part  of  the  nerve  trunk. 

Causes. — Anstie  regards  senility  as  a  predisposing 
cause,  and  Gueneau  de  M  ussy  J  looks  upon  sciatica  as 


*  See   some  very  judicious   remarks  on   this  subject  in 
Lasigue,  Etudes  MedicaUi,  p.  310. 

f  Las6gue,  Etudes  Medicates,  Vol.  II.     Art.  Sciatica. 
{  Gueneau  de  Mussy  Clinique  Medicate,  t.  i.,  p.  306. 


~Jh!^taiimSSiSidiiii'-^:i^--,il»^iJi:i:,aaiid^^il-'^U'^- 


—  52  — 
a  manifestation  of  a  rheumatic  or  arthritic  diathesis. 
The  great  length  and  superficial  position  of  the  sciatic 
nerve  renders  it  peculiarly  liable  to  inlammation  from 
cold  and  to  injuries,* 

Among  the  accidental  causes  are  exposure  to  cold, 
and  especially  damp  cold,  wounds,  contusions, 
neuritis,  fractures,  the  presence  of  abdominal,  pelvic, 
stercoral  tumors,  pressure  of  the  fcEtal  head  during 
accouchment,  etc.  Erb  regards  mechanical  pressure 
by  sitting  on  hard,  uncomfortable  seats  as  a  frequent 
cause. 

Excessive  walking  and  occupations  requiring 
prolonged  standing  certainly  sometimes  seem  to  favor 
if  not  directly  cause  sciatica,  and  I  have  seen  one  ob- 
stinate case  accompany  diabetes  as  a  part  of  the  de- 
cadence and  mal-nutrition  resulting  from  that  disease. 

The  disease  is  oftener  seen  in  robust  and  hard- 
working men  than  in  delicate  nervous  persons,  is 
more  frequent  in  middle  life  than  at  any  other  epoch, 
and  in  males  than  in  females.  According  to  Erb's 
observations,  the  proportion  of  males  to  females  is  as 
4  to  I. 

Symptoms. — The  disease  generally  announces 
itself  by  a  feeling  of  numbness,  tingling,  cold  or 
heat  in  the  entire  limb,  or  in  certain  limited  parts; 
then,  after  a  variable  time,  there  is  an  outbreak  of  pain 
which  may  occupy  different  branches  of  the  nerves 


*  Erb  in  Ziemssen's  Cyclopadia. 


i  ■ 


SIS. 

itic 
om 

)ns, 
fie, 
ing 
ure 
ent 

ing 
vor 
ob- 
de- 
[ise, 
ird- 
,,  is 
)ch, 
rb's 
s  as 

ices 
I  or 
rts; 
)ain 
rves 


—  53  — 
(genito-crural,  cutaneous  femoral  branches  of  the 
lesser  sciatic,  articular  branches  of  the  great  sciatic 
and  peroneal,  internal  saphenous,  short  saphenous  or 
posterial  tibial,  or  terminal  plantar  nerves).  As  in 
the  other  neuralgia.s,  the  pain  may  be  looked  upon  as 
douNe;  there  is  a  continuous  element,  a  deep,  contu- 
sive  pain,  and  a  paroxysmal  element,  manifesting 
itself  by  ascending,  descending,  or  irregular  lancina- 
tions*. 

"  Under  the  influence  of  walking,  muscular  exer- 
tion, heat,  or  without  any  known  cause,  lancinating 
pangs,  are  experienced  radiating  along  the  course  of 
the  nerve;  the  patient  can  often  mark  out  with  his 
finger  the  track  of  the  painful  nerve.  These  pains 
are  exasperated  by  pre.ssure  and  by  movement.  The 
patient  instinctively  seeks  repose  and  avoids  all  mus- 
cular contractions,  lying  on  the  opposite  side  from  the 
pain.  In  some  cases  the  patients  feel  in  the  bones 
and  joints  a  sort  of  a  deep  and  piercing  pain,  which, 
according  to  Jaccoud,  indicates  an  intra-vertebral 
origin  of  the  neuralgia.  When  there  are,  moreover, 
alterations  of  sensibility,  consisting  in  formications, 
tingling,  aching  sensations  in  the  back,  the  neuralgia 
has  for  its  origin  a  lesion  of  the  cord  or  meninges 
acting  on  the  posterior  columns. 

Apart  from  the  attack  some  patients  suffer  little 
and  are  able  to  work.     Others  become  incapacitated, 


•Jaccoud,  Path.  Interne,  i.  i,  p.  502. 


-■■i«i«SiliS*««»JS^S^«*?.-BS^»»iu<*Sst,ia'«^^ 


35»-(S.B,SKS:CS!4--.aBE^y 


—  54  — 
walk  with  difficulty,  limpin(j:,  or  even  are  compelled  to 
cease  walking  altogether. 

Hesides  these  pains,  disorders  of  the  cutaneous 
sensibility  have  been  noted,  and  Hubert  Valleroux  de- 
scribes sensory  troubles  (pertaininjj  to  tactile  sensibil- 
ity, sensibility  to  temperature,  etc.),  especially  occu- 
pying the  posterior  region  of  the  thigh,  or  four  or  five 
fingers'  breadth  below  the  popliteal  space;  atrophy  of 
the  affected  member  has  been  noted;  a  slow,  muscular 
atrophy  in  the  pure  neuralgias,  a  more  early  atrophy 
in  the  neurites.  Some  writers  have  observed  changes 
in  the  temperature  and  in  the  color  of  the  skin, 
erythema,  furunculi,  patches  of  herpes  along  the  tract 

of  the  nerve. 

Sciatica  has  a  very  irregular  march.  It  may  cease 
spontaneously  and  periodically;  its  duration  is  very 
variable,  from  several  days  or  weeks  to  years.  Re- 
lapses are  frequent."* 

Trfatmen/.—'lhG  general  principles  of  treatment 
applicable  to  the  other  neuralgias  are  applicable   to 

sciatica. 

Of  the  new  methods  of  treatment,  the  chloride  of 
methyl  spray  is  perhaps  the  most  noted.  A  peculiar 
apparatus  is  needed  to  carry  out  this  treatment,  which 
is  attended  with  congelation,  smarting  and  burning, 
but  afterwards  with  marvellous  relief.  Dujardin- 
Beauraetz  says  that  in  real  sciatica  he  has  generally 


•  Reprinted  from  "Clinical  Therapeutics. 


M 


to 

IU8 

ie- 

:u- 
ive 
of 
lar 
)hy 
ges 
cin, 
act 

ase 
ery 
Re- 
lent 
to 

e  of 
iliar 
lich 

ing. 
din- 
ally 


-  55  — 
found  the  pain  to  ceasi  after  mie  or  two  c'i|)|)lii:ati()ns 
of  chloride  of  methyl  spray.     (See  the  subject  treated 
fully  in   New  Medications,  pid)lished  by  (1.   S.  Davis, 
Detroit,  pajje  2S5.) 

The  ether  spray,  directed  over  the  affected  nerve 
or  nerves,  jjave  jf^eat  relief  to  one  of  my  patients  in 
his  atrocious  paroxysms. 

Cotuj^Mo  was  the  lirst  to  propose  canlharides 
blisters,  and  all  subsequent  authorities  have  spoken 
well  of  them.  The  blisters  should  be  of  the  size  of 
the  palm  of  the  haiul,  and  ap|)Iied  at  intervals  of  two 
or  three  days  over  the  painful  regions.  Anstie  recom- 
mends blistering  to  the  sacrum  -the  blisters  may  be 
dressed  with  some  simple  ointment  and  healed,  then 
put  on  again. 

The  actual  cautery  has  been  recommended  by 
Valleix,  Jobert,  and  others — light,  superficial,  "  trans- 
current  "  cauterization  being  employed. 

Faradization  by  the  electric  brush  has  had  its 
advocates.  Krb  has  seen  brilliant  cures  from  galvan- 
ism of  the  affected  nerve — the  anode  being  placed 
upon  the  .sciatic  foramen,  or  sacrum,  and  the  cathode 
upon  the  specially  painful  parts. 

Among  specific  remedies,  oil  of  turpentine  has 
been  extolled;  oil  of  turpentine,  3  j,  honey,  §j;  a 
tablespoonful  twice  daily. 

Neurotomy  and  nerve-stretching  have  not  given 
very  satisfactory  results;  neurotomy  is  not  to  be  rec- 
ommended except  when  the  pain  is  confined  to  a 
small  branch. 


^sSSi»»SS>iSiBtUSa»S's««9W«4S«»i«>SWSifia><<«-i^ 


=i-4«-<*BtSSS«K(F'" 


■Iji- 


'i; 


_  S6  - 

But  almost  always  the  resort  must  be  had,  sooner 
or  later,  to  chloroform  injections,  antipyrin  injections, 
or  to  narcotics.  The  deep  injection  of  chloroform 
into  the  substance  of  the  gluteal  muscle  over  the 
nerve,  is  Bartholow's  method;  (see  Appendix,  page 
ii6).  Antipyrin  may  also  be  used  to  advantage  hypo- 
dermically  (see  also  Appendix,  article  "  Antipyrin"). 
Opium  may  be  used  in  the  form  of  enema;  30  drops 
of  laudanum  to  2  ounces  of  thin  starch,  the  injection 
to  be  retained.  Generally  the  narcotic  will  be  more 
speedy  and  effectual  if  employed  in  the  form  Of  mor- 
phine injections  subcutaneously  administered  (for  di- 
rections, see  Appendix,  article  "  Opium  ").  Hammond 
gives  instances  where  the  hypodermic  of  morphine 
was  given  every  day  for  three  or  four  months.  This 
treatment  would  be  quite  certain  to  make  a  morphio- 
maniac  of  the  patient. 

Doubtless,  in  the  congestive  attacks  produced  by 
cold,  revulsion  by  irritant  liniments  (menthol,  turpen- 
tine, etc.)  and  vesicants  do  the  most  good,  while  in 
the  purely  rheumatic  form  benefit  may  be  expected 
from  a  prolonged  course  of  iodide  of  potassium. 


/./ 


ler 

IS, 

:m 
he 
ge 
•o- 

•)• 
ps 

on 

ire 

)r- 

ii- 

nd 

ne 

lis 

io- 

by 
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in 
ed 


i 


/ 


CHAPTER  V. 

VISCERAL   NEURALGIAS. 

The  internal  organs  are  mainly  supplied  with 
nerves  from  the  great  sympathetic.  Although  the 
ganglionic  nerves  are  sensory  as  well  as  motor,  yet 
the  sensibility  of  the  sympathetic  system  differs  in 
many  respects  from  that  of  the  cerebro-spinal  system. 
In  the  normal  functionment  of  organs  innervated  by 
the  sympathetic,  there  is  little  sensibility  and  never 
pain.  We  are  not,  for  instance,  in  health  cognizant 
of  the  state  of  our  digestive  tube  during  digestion; 
the  changes  which  the  food  is  undergoing  do  not 
enter  as  an  element  into  our  consciousness,  unless,  it 
may  be,  in  contributing  to  a  massive,  vague,  indefin- 
able sensation  of  bien-etre,  called  by  Maudsley,  can- 
asthesis*  In  pathological  states,  however,  the  sen- 
sory elements  of  the  sympathetic  declare  their  exist- 
ence by  vague  impressions  of  discomfort,  if  not  by 
actual  pain.  Pain  of  a  severe  kind  is  experienced  in 
gastric  cancer  as  well  as  in  gastralgia,  in  enteritis,  etc., 
and  the  uterus,  which  in  the  normal  state  is  insensi- 
tive, in  various  morbid  conditions  may  be  the  seat  of 
severe  pain. 


*"The  general  feeling  of  well  being  which  results  from 
a  healthy  condition  of  all  the  organs  of  the  body  *  *  *  is 
known  as  the  canasthesis."  Maudsley,  Physiology  and  Path- 
ology of  the  Mind,  page  135. 


■smm-Tm-^'tssmiisit^^i.mi&::.ei^eii>^tii^t.^. 


♦to..™— ...^"" 


111 
■1l 


-  58- 

In  neuralgia  of  the  viscera,  the  pain  is  deep 
seated,  sometimes  a  dull,  heavy  ache,  sometimes  of  a 
boring  character,  rarely  lancinating.  "  It  does  not 
dart,  like  the  pain  of  superficial  neuralgia,  but  is 
either  constant  or  comes  in  waves  which  steadily 
swell  to  a  maximum  and  then  die  away,  often  leaving 
the  patient  in  a  state  of  profound  temporary  prostra- 
tion "  (Putnam).* 

The  pain  is  generally  diffused,  and  there  are  no 
definite  points  douloureux  although  the  organ  may  be 
tender  to  touch.  In  severe  attacks  there  are  painful 
irradiations,  as  in  the  superficial  neuralgias.  Pressure 
generally  relieves  the  pain,  it  never  provokes  an  at- 
tack. 

General  disorders  like  those  that  attend  the  neu- 
ralgias of  the  cerebro-spinal  system  accompany  the 
visceral  neuralgias,  in  virtue  of  the  law  that  one  part 
cannot  suffer  without  entailing  suffering  on  the  whole. 
Besides  the  loss  of  appetite  and  the  decadence  in  the 
nutritive  functions  with  consequent  emaciation,  there 
are  reflex  disturbances  which  are  often  of  a  serious 
natur'e;  witness  the  nausea,  vomiting,  indigestion,  con- 
stipation, which  attend  uterine  or  ovarian  neuralgia. 
The  functions  of  the  organ  which  is  the  seat  of  the 
neuralgia  are  also  more  or  less  disturbed  or  interrup- 
ted; thus,  in  gastralgia,  digestion  is  suspended,  and 
food,  if  taken,  provokes  vomiting. 


*  Pepper's  Syst.  American  Medicine,  Vol.  v,  page  1215. 


Sa.;;j,c.-s; 


—  59  — 

It  is  needless  to  say  that  hi  causes  of  visceralgia 
are  the  same  as  those  which  pr^'juce  neuralgias  of  the 
cerebro-spinal  system,  and  that  neuralgias  of  the 
sympathetic  are  often  interchangeable  with  the  super- 
ficial neuralgias  which  occur  in  states  of  anaemia  and 
prostration,  in  persons  of  a  neuralgic  habit,  etc. 

Uterine  and  Ovarian  Neuralgia. — It  is  now  gen- 
erally conceded  that  the  uterus  is  sometimes  the  seat 
of  a  suffering  which  is  essentially  neuralgic.  There 
is,  for  instance,  a  form  of  dysmenorrhoea  called,  by 
common  consent,  neuralgic.  The  pain  is  independ- 
ent of  all  organic  disease;  it  is  not  due  to  any  ob- 
struction to  menstruation,  but  attends  the  monthly 
function  on  account  of  an  exaggerated  irritability  of 
the  ovaries.  The  pain  manifests  itself  before  or  after 
the  beginning  of  menstruation,  and  may  cease  when 
the  flew  becomes  established,  or  may  continue  through 
the  period.* 

In  some  patients  the  whole  period  is  one  of  in- 
tense suffering;  commencing  'with  sharp,  darting, 
lancinating  pain  in  the  uterus  and  vagina,  and  extend- 
ing down  the  thighs.  There  is  often  severe  reflex 
pain  in  one  or  both  breasts. 

Hysteralgia  is  sometimes  coincident  with  neural- 
gic affections  of  the  cerebro-spinal  nerves,  sometimes 
it  takes  the  place  of  the  latter;  it  is  apt  to  occur  in 
persons  of  the  neuralgic  disposition. 


•Jenks,  Diseases  of  Menstruation,  Detroit,    1887. 


'>'£Slli@9aa)niisa«k)C£Siw  tmsSiisu^i.iiiim^-x'Jut.i 


»Mu=>£^'^il.^i»iWi;<«i^^.^^^tl^^>';'.^ut^r.^4.*^i£^J^^»U!^»^^<^ 


;.^*«T!***&;!^*U£!Si*v?-  ^i^*^cri-.--  ri1¥w.-> 


—   60   — 

Anstie  speaks  of  a  class  of  cases,  which,  I  believe, 
are  sufficiently  common  in  the  experience  of  physi- 
cians, where  the  affection  "appears  to  be  a  severe 
ovarian  neuralgia,  attended  with  a  vaso-motor  par- 
alysis which  causes  great  engorgement  of  the  ovary 
and  consequent  difficulty  of  ovulation."  *  He  also 
believes  that  peri-uterine  neuralgia  is  often  due  to 
peripheral  irritation,  arising  from  such  sources  as  the 
following:  Ascarides  in  the  rectum;  profuse  and 
irritable  leucorrhoea;  calculus  in  the  kidney  and 
ureter;  prolapsus  uteri;  tumors  in  the  uterus  or  its 
appendages;  ulcer  of  the  cervix;  large  masses  of 
scybalous  faeces  in  the  rectum,  etc. 

Treatment. — In  the  endeavor  to  alleviate  uterine 
neuralgia,  the  general  principles  of  treatment  to  be 
hereafter  set  forth  are  applicable.  A  fortifying  regi- 
men is  to  be  insisted  upon,  of  which  exercise  in  the 
open  air  is  an  essential  part.  All  delicate  females  are 
the  better  for  judicious  gymnastic  training.  Hydro- 
therapy properly  admfnister  •  is  a  powerful  adjuvant 
to  the  treatment.  Some  casts  ol  neuralgic  dysmen- 
orrhoea  are  cured  by  marriagi. 

The  diathesis  should  be  kept  in  view;  ansemic 
and  chlorotic  patients  require  iron,  arsenic,  strychnia, 
and  all  the  elements  of  the  haematic  and  tonic  regi- 
men. Rheumatic  cases  demand  salol,  iodide  of 
potassium,  and  especially  guaiacum.     Dewey's  ammo- 


•  Anstie,  on  Neuralgia,  Etc.;  Am.  ed  ;  p.  72. 


I 


—  6i   — 

niated  tincture  has  had  considerable  repute  in  rheu- 
matic dysmenorrhoea. 

Jenks*  speaks  favorably  of  electricity;  a  mild 
galvanic  current  down  the  spinal  column  for  ten  min- 
utes, and  a  strong  current  through  the  pelvis;  the 
whole  sitting  not  to  exceed  twenty-five  minutes. 

Among  the  external  remedial  agencies,  revulsive 
applications  to  the  os  and  cervix  with  the  Paquelin 
cautery,  or  the  acid  nitrate  of  mercury  have  the  en- 
dorsement of  Dujardin-Beaumetz.f 

Narcotics  will  often  be  required  where  simpler 
remedies  fail  to  relieve  the  pain,  and  here  supposi- 
tories of  opium,  morphine,  belladonna,  will  render 
good  service.  Jenks  gives  several  formulae  in  his 
useful  little  book  on  the  Disorders  of  Menstruation, 
which  belongs  to  the  series  of  1887.  The  morphine 
suppository  of  the  U.  S.  Ph.  has  proved  useful  in  my 
practice.  Lavements  of  thin  starch  and  laudanum 
have  also  promptly  relieved  the  pain. 

Of  late,  antipyrin,  by  mouth,  hypodermic  injec- 
tion, or  lavement,  has  been  attended  with  excellent 
results.  Germain  S^e  especially  recommends  the  ad- 
ministration by  lavement.  The  following  formula 
may  be  employed  :  Antipyrin,  3  i;  .starch,  |  ij.  M. 
For  one  injection,  which  should  be  retained. 

Jenks  speaks  well  of  cimicifuga  racemosa,  begun 


*  Loc.  eit.,  p.  60. 

f  Clinical  Therapeutics,  Detroit  ed.,  page  73. 


-^^!iAi«f^iiiSS:i^ii«i^>Sa,-eii&»^ii^^A*^m^iisltit^itS!gM 


— V.V)i*,%fe.;i^-*».t-vi,=.iiia 


—    62    — 

two  or  three  days  before  the  flow,  and  continued  at 
brief  intervals  through  the  entire  period.  The  dose 
would  be  half  a  fluid  drachm  to  a  drachm  every  four 
or  six  hours.  The  tincture  of  pulsatilia  in  three- 
drop  doses  every  two  hours  while  the  pain  lasts  has 
been  highly  recommended. 

The  fluid  extract  of  black  haw  (viburnum  pruni- 
folium)  in  teaspoonful  doses  every  four  hours  has 
achieved  good  results  in  neuralgic  dysmenorrhcea. 
The  liquor  sedans  of  P.,  D.  &  Co.  has  viburnum  pruni- 
folium  along  with  Jamaica  dogwood  and  hydrastis 
Canadensis. 

Neuralgias  of  the  bladder,  urethra,  testicle,  and 
spermatic  cord,  have  been  observed.  A  neuralgia  of 
the  liver,  under  the  name  of  hepatalgia,  has  also  been 
described.  A  more  common  form  is  neuralgia  of  the 
stomach,  known  as: — 

Gastralgia,  or  gasirodynia. — This  is  a  very  painful 
affection,  met  with  in  persons  of  a  delicate,  neuro- 
pathic temperament.  It  is  often  associated  with 
anaemia,  sometimes  with  hysteria.  In  other  cases, 
arthritis  is  the  underlying  element.  One  very  severe 
case  which  came  under  my  observation  attended  over- 
work and  lactation  in  a  patient  who  had  been  a  suf- 
ferer from  neuralgia. 

It  is  probable  that  gastralgia  is  a  neuralgia  of  the 
pneumogastric  nerve,  as  the  stomach  is  supplied  with 
sensory  as  well  as  motor  fibres  from  that  nerve. 

The  special  characteristics  of  true  neuralgic  pain 


at 

ise 
ur 
:e- 
las 

ni- 
las 
sa. 
ni- 
;tis 

nd 
of 
len 
:he 

ful 
ro- 
ith 
;es, 
ere 
er- 
uf- 

the 
ith 

ain 


_  63  - 

in  the  abdominal  pneumogastric  nerve,  are:  (i)  It 
comes  on  in  states  of  exhaustion;  (2)  unlike  dyspep- 
tic pains,  it  is  relieved  by  food;  (3)  it  is  also  relieved 
by  stimulants,  as  brandy  and  water,  thus  resembling 
colic;  (4)  it  is  diminished  by  pressure,  which  aggra- 
vates most  pains  dependent  on  local  organic  mischief 
(Anstie).  "  The  most  severe  example  of  gastralgia 
which  I  have  ever  seen,"  says  Anstie,  "  was  entirely 
unaccompanied  by  dyspepsia;  this  patient  absolutely 
attempted  suicide  to  escape  from  his  agonizing  pains, 
which  recurred  with  the  greatest  frequency  and 
obstinacy,  but  were  at  last  entirely  removed  by 
strychnia." 

Although  gastralgia  is  not  dependent  on  dyspep- 
sia, it  is  sometimes  provoked  by  food,  even  of  a  bland 
and  digesti ale  character,  just  as  neuralgic  attacks  of 
the  peripheral  nerves  are  frequently  provoked  by 
ordinary  stimuli.  One  marked  instance  of  this  kind 
has  come  under  my  observation,  which  was  in  this 
sense  an  e.xeption  to  the  rule  as  laid  down  by  An- 
stie.* 

Treatment.— C&usa\  indications,  as  far  as  possi- 
ble, must  be  attended  to;  anaemia  and  chlorosis  de- 
mand  the    appropriate    remedial    agents.      Leubef 


*  Mrs.  A. ,  living  in  Beck  street,  Newburyport,  for  weeks 
a  sufferer  from  typical  gastralgia  attacks,  which  at  certain 
times  were  brought  on  by  anything  whatever  introduced  into 
the  stomach,  and  were  not  relieved  by  free  vomiting. 

f  Ziemssen's Cyclop.,  vol.  vii.,  p.  306. 


ii<«,t^iM^S;S«^SwwAaSk.->fifci.lV.'i-^'-?i*«*SS(»«aft*«30PSSIWlK1'J^^ 


!  I 


It 


,  !     ;, 

t       I 


lii: 


^ 


,  -:=iit-K- — irr- 


-   64  - 

speaks  favorably  of  the  lactate  of  iron  in  3-grain 
(loses  with  equal  parts  of  aromatic  powder  or  extract 
of  cinchona. 

In  gastraljfia  due  to  hysteria,  arthritis,  etc.,  the 
underlying  diathesis  must  be  treated.  Gouty  or 
lithajmic  patients  require  alkalies  (Vichy  water,  lithia, 
potas.  carbonate),  colchicum,  saline  laxatives,  the 
proper  dietary  regimen,  and  possibly  a  derivative 
treatment.  Garrod  recommends  that  the  attempt  be 
made  i)y  warmth  and  counter-irritants  to  excite  deriv- 
ation to  the  joints. 

If  the  stomach  be  in  such  a  hyperaesthetic  condi- 
tion that  food  excites  the  pain,  it  is  still  better  that 
food  be  taken ;  there  is  nothing  gained  by  a  starva- 
tion treatment. 

As  special  remedies,  Anstie  speaks  highly  of  nux 
vomica;  ten  drops  of  the  tincture  to  be  taken  three 
times  a  day.  The  hyperaesthetic  stomach  is  some- 
times benefited  by  full  doses  of  bismuth,  or  oxalate  of 
cerium.  Hypodermics  of  morphine  may  be  demand- 
ed. Leube  especially  recommends  galvanism:  ten  to 
fifty  elements,  the  anode  upou  the  painful  point  of 
the  epigastrium,  the  cathode  on  the  left  axillary  line; 
the  application  to  be  kept  up  from  five  to  ten  min- 
utes.* 


♦  Leube,  iec.  cit. 


jrain 
tract 

,  the 
y  or 
thia, 
the 
ative 
)t  be 
eriv- 

jndi- 

that 

irva- 

'  nux 
three 
ome- 
iteof 
land- 
en  to 
It  of 
line; 
min- 


_  65  - 

ANGINA      FKCTORIS     AND     THK     TRUK     (  AROIAl'      NKU- 
RA  I.e.  I  AS. 

There  is  a  form  of  cardiac  pain  which  is  always  of 
bad  prognosis,  because  indicative  of  organic  and  gen- 
erally incurable  lesion.  It  was  first  correctly  described 
by  Rougnon,  and  nearly  simultaneously  by  Heberden, 
in  1768;  it  was  afterwards  called  Heberden's  disease, 
though  Heberden  gave  it  the  name  of  ani:;hni  pectoris, 
the  word  angina  being  indicative  of  the  peculiar  an- 
guish accompanying  the  attack.  Seneca,  who  appears 
to  have  been  a  sufferer  from  angina  pectoris,  speaks 
in  one  of  his  letters  of  the  suddenness  of  its  invasion, 
which  he  compares  to  the  impetuousness  of  a  tempest 
{brevis  impetus, prore/la:  simi/is);  and  he  adds  that  the 
predominant  .sensation  is  one  of  angui-sh  as  of  impend- 
ing death. 

This  kind  of  cardiodynia  has  its  seat  in  the  ter- 
minal cardiac  filaments  of  the  pneumogastric  nerve, 
and  is  due  to  ischajmia  of  the  heart  muscle.  The 
old  theory  was  that  angina  pectoris  is  a  primary  or 
symptomatic  neurosis  of  the  cardiac  plexus.  This  is 
denied  by  the  best  recent  authorities,  who  compare 
the  pain  to  that  attending  gangrene  from  occlusion  of 
an  artery. 

"  Let  us  suppose,"  says  Germain  See,*  "  that  the 
myocardium  receives  less  than  its  normal  quantity  of 


•  G.  S6e:  Maladies  du  Coeur,  2d  ed.,  1883,  p.  30, 

3  Mil 


»eiw^^u;3jMsi«,<AAftf^^An)«!'^ii-«?^^v^jK-<Mi«()i»«a< 


-M 


_  66  — 

blood;  the  terminal  extremities  of  the  vajjns  will  re- 
ceive less  also.  Now  olig;vmia  of  a  sensory  nerve 
manifests  itself  by  pain.  'I'his  oliKivniia  also  accounts 
for  the  peculiar  distress,  the  anger." 

Huchard.  in  a  recent  work  on  arterio-sclerosis 
and  the  arterial  cardiopathiesf,  which  is  the  most 
complete  by  far  that  has  yet  appeared,  sums  up  the 
numerous  anatomatical  and  other  theories,  and  gives 
weighty  reasons  for  the  view,  which  he  holds  in  com- 
mon with  IJalfour,  Kreysig.Tiedemann,  Potain,  Parry, 
Liegois,  S^e,  and  others,  that  true  angina  pectoris  is 
always  dependent  on  lesions  (sclerosis,  thrombosis, 
atheroma,  sometimes,  however,  spasm)  of  the  coronary 
arteries,  with  ischemia  of  the  myocardium.  The  or- 
dinary lesion  is  arterio-sclerosis,  which  is  sometimes  of 
toxic  origin  (diathetic,  alcoholic,  nicotinic),  sometimes 
a  senile  degeneration. 

There  is  an  angina  pectoris  which  ends  almost 
always  in  sudden  death;  there  are  other  kinds  of  car- 
diodynia,  quite  as  distressing,  which  almost  invariably 
terminate  in  recovery.  The  latter  are  functional  and 
nervous.  Huchard  ranges  the  latter  under  the  head 
of  false  angina  pectoris  (pseudo  angina);  they  con- 
stitute the  true  neuralgine  of  the  heart. 

Huchard  divides  the  peculiarly  neuralgic  forms 
into  three  classes:  the  neurotic,  the   reflex   and    the 


fHuchanl:    Maladies  du   Coeur  et  dc8  Vaisseaux,  etc., 
Paris,  1889. 


*   t 


I  re- 
erve 
tints 

rosis 
most 
the 
jives 
aom- 
arry, 
'is  is 
)osis, 
inary 
e  cr- 
ies of 
;imes 

most 
car- 
iably 
I  and 
head 
con- 

orms 
1   the 

;.  etc., 


-  67  - 

toxic.  He  formerly  added  a  fourth  the  diathetic; 
but,  he  is  now  cunviced  that  this,  as  a  separate  class, 
has  no  raison  d'etre. 

(i.)  The  neurotic  is  that  painful  condition  of 
the  cardiac  innervation  which  has  its  origin  in  the 
state  of  the  nervous  system  accompanying  hysteria, 
neurasthenia,  hypochondria,  exophthalmic  goitre, 
spinal  irritation,  neuro-arthritism,  and  (according  to 
some  authors)  epilepsy. 

(2)  The  reflex  form,  of  peripheral  or  visceral 
origin,  takes  its  point  of  departure  in  some  distant 
irritation,  as  of  the  stomach,  uterus,  etc.,  which  is  re- 
flected on  the  cardiac  plexus.  Huchard,  under  this 
head,  gives  instances  of  reflex  pseudo-angina  accom- 
panying intercostal  neuralgia,  painful  peripheral  ex- 
citation of  the  nerves  of  the  extremities,  neuromata, 
and  neuralgia  of  the  left  arm. 

(3)  The  toxic  form,  is  perhaps,  oftener  caused 
by  tobacco  than  by  any  other  agent,  and  this  (the 
nicotinic)  is  given  as  the  typical,  toxic  species,  though 
cases  have  been  referred  to  tea,  coffee  and  alcohol. 
There  is  a  functional  cardiodynia  from  tobacco-smok- 
ing relatively  benign,  resulting  from  spasm  of  the 
coronary  arteries;  this  Huchard  calls  spasmo-nicotinic 
angina.  There  is  another  kind,  also  due  to  abuse  of 
tobacco,  which  »s  dependent  on  arterio-sclerosis;  he 
calls  it  scUro-nicotinic  angina. 

The  following  table  from  Huchard,  gives  the 
principle  distinctive  features  of  the  true  and  spurious 
anginae : 


■'^-Btoiftisywi  •j»M^a^»^qiE^irii.^sJ^^.iai»U.^»M^'j:  -»A^i*lie^J^^-: 


li  i 

;!  ii 


—  68  — 

THUl,    AUTHIAL  ANOINA   PECTORIS. 

Anatomical  Caw/.— Aortitis,  with  obliteration  of  the  core 
nary  arteries.  Sclerosis,  with  constriction  or  obliteration  oi 
the  coronaries.     An  arterial  affection. 

Symfloms.—VtAM  almost  always  paroxysmal,  not  per- 
manent, provoked  by  walking,  emotional  excitement,  effort. 
Rarely  periodical  and  nocturnal  attacks.  Cardiac  pain  isolated 
from  other  neurotic  symptoms.  Agonising  pain,  with  sensa- 
tion of  compression  as  a  vise.  Pains  of  short  duration,  ceasing 
with  repose.     Sub-sternal  seat  of  the  pain,  generally  over  the 

aorta. 

Attitude  of  the  Patient.— SWtnct,  arrest  of  all  movements, 
the  pain  ceasing  with  absolucc  rest.  No  painful  points,  but 
tho  latter  may  be  present  ivhcn  true  angina  is  complicated  with 
cardiac  and  phrenic  neuritis  by  propagation  of  the  peri-arleritis 
to  the  plexuses  of  nerves  in  the  vicinity.  Often  substernal 
anguish  without  pain. 

Prognosis.— Tiut  angina  pectoris  Is  almost  always  fatal. 

7Wri//w*»«/.— Arterial  medication.  Revulsives  of  no  ac- 
count. 

fai.sk,    neuralgic  angina. 

Anatomical  O/kjm.— Aortitis  with  neuritis  of  the  cardiac 
plexus.  Hyperamla  ol  the  cardiac  plexus.  Neuralgia  of  the 
cardiac  plexus.  A  neuralgic  or  neuriiic  affection.  Often  (aa 
In  hysteria)  a  vasomotor  neurosis. 

Symptoms.— Vsi\n%  less  frankly  paroxysmal,  often  peri- 
odical, coming  on  at  the  same  hour  (hysterical,  neurasthenic, 
pseudo-angina);  not  provoked  by  effort,  but  often  caused  by 
cold.  Attacks  frequently  periodical,  recurring  at  fixed  hours, 
and  nocturnal.  Cardiac  pain  associated  with  other  neurotic 
symptoms.  Pain  less  agonizing,  wlih  sensation  of  distention 
of  the  heart.  Pains  of  long  duration,  not  ceasing  by  repose. 
Seat  of  the  pain  often  frankly  cardiac. 


I 


f  !iS 


lii^ 


—  6rf  —' 

Alliiu<lf  of  the  AiZ/Vx/.— Incessant  aKitatinn.  Continu- 
ance of  walking;  rest  brinm  no  diminuiion  of  the  pain  ExNt- 
encr  of  points  painful  to  pressure,  er perially  alonfj  the  trart  o( 
the  phrenic  nc'ves  (neuritis  of  the  car'liac  plexus  and  of  the 
dlaphraRmalic  nerve).  Anguish  less  pronounced,  always  asgo- 
dated  with  the  pain.  I'seudo  angina  is  never  fatal,  except  in 
cases  where  the  cardiac  neuritis  is  ussoiialed  with  coronary 
tclerosis. 

7Vcrj/w/>«/.— Anti-neural«ic  rpme<lics.  Revulsives  often 
beneficial. 

KEFt,FX,    NRURALfMC,    PSKtMXJ-ANdlNA    PKCIORIS. 

A  nervous  afTtti  tion. 

.S>w//,.«/j,— Attacks  spontaneous  at  times,  but  often  pro- 
foked  by  movements  of  the  left  arm,  and  by  pressure  over  the 
painful  nervts.  Depends  on  some  other  (peripheral)  neuralgia 
(brachial,  dorso-intercostal),  on  gastric  or  other  visceral  dis- 
order,  [s  observed  at  all  ages.  Attacks  long,  not  provoked 
by  effort.  Attention  is  early  called  to  the  visceral  or  other. 
afTection.  Pain  precordial,  with  feeling  of  distention;  little 
irradiation  to  arm  and  neck.  In  gastric  pseudo-angina.  signs 
of  dilatation  of  the  stomach  often  accompany  it.  Prognosis  be- 
nign, never  terminates  in  death, 

yVfdi'w.'M/.— Revulsives,  calmatives,  anti-neuralgic  reme- 
dies,  anti-dyspeptic  remedies. 

TO,\IC  I'Sf^UDU  ANOINA  (KRUM  TOBACCO). 

(Generally  by  spasm  of  the  coroniries.) 

5)'/»/»/(PWj.— Attacks  of  angor,  generally  associated  with 
other  phenomena  of  a  toxic  kind;  vertigo,  gasltic  and  respira- 
tory troubles,  etc.  Cardiac  pain  accompanied  by  other  func- 
tional heart  symptoms,  >uch  as  palpitations,  intermittences, 
arythmia,  lipothymia,  etc.  Attacks  long.  Paroxysms  gener- 
ally spontaneous,  rarely  provoked. 

Prognosis. — Rapid  disappearance  of  the  symptoms  by 
•oppression  of  the  toxic  cause. 


■»irafrili>  »'Mi   t;jiriiiii^Wiffl9»*rfjewja«.^g.:fia!.  i^)ii;^«>4e-'y:<^i=i 


,^ 


i     I 


—  70  — 
Huchard  gives  an  exemplification  of  the  difficulty 
under  which  the  clinical   observer  must  sometimes 
labor  in  diagnosticating  the  affection.      "  In  gout  he 
may  have  thoracic  anger  under  three  conditions:   (a) 
it  is  either  a  true  angina,  arising   from   an   arterial 
lesion    (arterio-sclerosis,    atheroma  of  the   coronary 
arteries,  lesions  of  the  aorta,  etc.)  to  which  gouty  per- 
sons are  always  predisposed;  or  {l>)  gastric  troubles, 
frequent  in  gouty  patients,  may  provoke   attacks  of 
false  angina  pectoris  which  may  terminate  in  recovery; 
or  (c)  the  angina  pectoris  may  be  a  neuralgic  attack, 
such  as  gouty  neurasthenic  invalids  are  prone  to." 

In  true  angina  pectoris,  the  leading  indication  is 
to  remedy  the  cardiac  ischa-mia  which  causes  the 
pain.  This  indication  can  be  only  partially  met  by 
the  so-called  vaso-motor  dilators,— nitrite  of  amyl 
(two  or  three  drops  to  be  inhaled  from  the  open 
palm);  nitro-glycerin  (frequent  drop  doses  of  the 
centesimal  solution);  and  iodide  of  sodium,  which,  ac- 
cording to  Huchard,  should  be  given  in  ten-grain 
doses  three  or  four  times  a  day  for  a  long  time. 
Hypodermics  of  morphia  seems  to  favor  the  capillary 
circulation,  as  well  as  allay  nervous  irritation,  and  will 
be  often  demanded  in  severe  paroxysms. 

In  the  pseudo  forms,  the  general  anti-neuralgic 
and  revulsive  treatment  will  be  called  for,  due  atten- 
tion being  given  to  the  cause,  whether  peripheral, 
visceral,  or  toxic. 


1   ! 


1  ^k. 


fr^TV■^^^■^WV^-r^ffW■.J;■^.^^*g-'ggH.^^J'■*W-'  " 


CHAPTER  VI. 

REFLEX  AND  TOXIC  NEURALGIAS. 

NEURALGIAS    DUK    TO  A  GENKRAL    MORBID  CONDITION. 

Reflex  neuralgias  are  caused  by  a  lesion  more  or 
less  distant  from  the  seat  of  pain.  The  irritation  is 
transferred  or  reflected  from  one  set  of  nerves  to  the 
terminal  filaments  of  another  through  the  medium  of 
the  cerebro-spinal  or  sympathetic  system.  The  sympa- 
thetic nerve  is  ordinarily  the  seat,  and  the  primary 
cause  of  the  pain  generally  resides  in  some  one  of  the 
viscera,  although  the  painful  reflex  may  start  in  a 
cerebro-spinal  nerve  branch;  an  iristance  of  this  is 
seen  in  the  severe  eye-ache  or  brow-ache  which  some- 
times attends  a  carious  tooth  that  may  itself  be  pain- 
less. Lisfranc  *once  obtained  the  cure  of  a  sciatica  by 
the  extirpation  of  a  painless  vaginal  polypus.  Other 
examples  of  reflex  neuralgias  are  found  in  the  hepa- 
talgia  accompanying  gastritis,  gastralgia  caused  by 
taenia,  cystalgia  due  to  an  affection  of  the  kidneys.f 


*Vanlair,   Loc.  cit. 

f  "When  no  local  pain  is  felt,  we  must  assume  that  the 
centre  to  which  the  apparent  impressions  directly  come  is  not 
thus  excitable  to  painful  activity,  or  even  so  as  to  influence 
consciousness,  but  that  it  is  in  connection  with  another  centre 
which  by  natural  or  acquired  susceptibility  is  disposed  to  ex- 
cessive action,"  "(Gowers'  Neuralgia,  Its  Etiology,  Diagnosis, 
and  Treatment,"  p.  27.)  The  above  is  esoentially  Vanlair's 
explanation  of  reflex  neuralgias,  where  the  pain  seems  to  spare 
the  sensory  centres  of  the  region  in  which  the  cause  exists,  to 
be  reflected  on  some  distant  centre. 


^sar-yia'cci^i.vft.v^is^ 


r,v;^i*il,wrt.:;.  .'*'rtjf^^jtv^-- 


I  "  ■.! 


.1      1 


.!  ..1 


—  72  — 

Eye-strain  is  a  fruitful  cause  of  headache  and 
neuralgia.  This  has  been  made  very  clear  by  Dr. 
Ambrose  L.  Ranney,  in  an  article  in  a  late  number  of 
the  Netv  York  Medical  Record: 

For  some  years  past  it  has  been  my  custom  to  examine 
repeatedly  anc!  with  care,  the  visual  apparatus  of  every  patient 
sent  to  me  for  the  relief  of  headache  and  neuralgia.  1  have 
already  published,  from  time  to  time,  many  cases  where  this 
line  of  research  has  been  followed  by  marked  and  permanent 
benefit.* 

I  deem  it  worthy  of  remark,  in  this  connection,  that  less 
Importance  is  being  attached  to  day  than  forn.erly  lo  the  clini- 
cal determination  of  modifications  in  the  calibre  of  the  blood- 
vessels of  the  brain. 

The  tondittins  known  as  "cerebral  congestion,"  or 
"  cerebral  anismia"  of  certain  authors  who  have  written  ex- 
tensively upon  headache  and  neuralgia,  are  very  often  the 
results  of  underlying  factors. 

Their  existence  (as  has  been  claimed)  may  sometimes  be 
revealfid  by  the  ophthalmoscopic  examination  of  the  vessels  of 
the  retina  and  confirmed  by  the  effects  of  nitrite  of  amyl  upon 
the  patient;  but  when  so,  they  are  probably  to  be  regarded 
rather  as  an  evidence  of  a  functional  derangement  of  the  vaso- 
motor system  of  nerves,  than  as  permantnt  factors  in  head- 
aches or  neuralgias. 

I  have  known  many  patients  who  have  followed,  with 
negative  results,  a  prolonged  course  of  treatment  (by  ergot, 
bromides,  amyl,  etc.),  which  was  based  upon  the  examination 
of  the  retinal  vessels,  and  I  have  often  seen  them  recover  from 
their  headaches  and  neuralgias  without  drugs  when  an  anomaly 
of  the  refraction  or  of  the  muscular  adjustment  of  the  eyes  was 
rr;- rcted. 

\  would  not  be  construed  as  denying  that  the  blood- 
vesaois  of  the  brain  iiiiglit  not  have  been  abnormally  dilatsd  oi' 
peculiarly  cotitracted  in  many  of  these  cases  at  the  time  when 
their  retinal  vessels  were  examined;  nor  would  I  utter'y  reject 


'New  y,irk  yfedha/  /ournai,  ianuarv,  tfSi;  Lectures  on  Nervous 
Disease.s,  Philadi-lphi.i,  i888  (F.  A.  Davis,  Publisher);  Medical  RegtiUr, 
Philadelphia,  November  ig,  1887. 


1'V 


md 
Dr. 

rof 


line 
ient 
lave 
this 
lent 

less 
lini- 
lod- 

'  or 
I  ex- 

the 

s  be 
Is  of 
ipon 
rded 
aso- 
ead- 

with 
rgot, 
ition 
from 
maly 
I  was 

iood- 
:d  or 
vhen 
eject 


rvous 
"isttr. 


—  73  — 

the  hypothesis  that  the  retina  sometimes  affords  us  a  valuable 
means  of  determining  by  our  sense  of  sight  the  condition  of 
the  cerebral  vessels  in  any  given  individual. 

What  I  do  mean  to  assert  is  this:  That  changes  in  the 
cerebral  circulation  (as  is  often  observed  in  the  case  of  a  blush 
upon  the  cheek)  may  be  caused  by  subtle  nervous  influences 
that  ergot,  bromides,  nitrite  of  amyl,  or  other  drugs  will  not 
arrest;  that  a  classification  of  headaches  or  neuralgias  which  is 
based  upon  so  variable  a  sign  is  unscientific;  and  that  any  line 
of  medication  which  is  directed  toward  this  condition  alone  is 
very  liable  to  be  unsatisfactory,  both  to  the  physician  and  his 
patient,  sooner  or  later. 

To  illustrate  this  point  I  will  mention  a  remarkable  ex- 
perience of  my  own  that  impressed  me  strongly  at  the  time. 

Some  ten  years  ago.  when  almost  in  despair  from  con- 
tinuous and  intractable  headache,  and  doubtful  of  my  ability  to 
long  endure  it,  two  oculists  of  equal  prominence  and  ability 
were  asked  by  me  to  examine  my  retina;  by  means  of  the 
ophthalmoscope. 

One  diagnosed  my  condition  as  "  typical  nicotine  poison- 
ing of  the  retina;"  the  other  discovered  what  seemed  to  him  to 
be  conclusive  evidences  of  "  congestion  of  the  brain,"  and  thit 
nothing  but  prolonged  rest  from  work,  in  his  opinion,  could 
relieve.  Neither  suggested  the  detection  of  any  "  lateral ''  re- 
fractive error,  or  the  use  of  glasses.  My  sight  was  apparently 
perfect  and  unusually  acute. 

Subsequently  the  instillation  of  atropine  into  my  eyes 
(which  was  used  at  my  earnest  solicitation)  and  the  correction 
by  proper  convex  glasses  of  a  hypermetropia  of  3.00  diopters 
(not  previously  suspected)  restored  me  to  health  and  comfort 
as  if  by  magic.  A  complete  and  immediate  cessation  of  all 
pain  for  over  nine  months  followed  the  correction  of  my 
refractive  error;  and  for  many  years  I  have  been  almost  en- 
tirely free  from  pain,  in  spite  of  continuous  eye-work  at  my 
desk  and  elsewhere. '^ 

Dr.  Ranney  reports  fifty  cases  of  headaches — 
supra-orbital,  f'ontal,  and  occipital  neuralgias,  which 
were  relieved  or  cured  by  tenotomy  of  the  recti  mus- 
cles, or  by  suitable  corrective  gUi^ses.  He  urges  the 
necessity  of  using  atropine  upon  a  patient  for  diag- 


*^'*««!4»Bl»*»*BHeBws.ttc.4Mfc.-^-»;"--, 


K  Htie*.»A<*.-4,JHa...i  ^, 


ii   i 
'  i   ■■' 


i  ;:!;  - 

■'itt 

iilt 

;!  ;li 
;:  1!  - 


—  74  — 

nostic  purposes  when  an  error  of  refraction   or  of 
accommodation  is  suspected. 

"  Personally,"  he  adds,  "  I  do  not  regard  an  examination 
as  complete  without  it.  It  solves  the  common  question  of  the 
presence  of  latent'  hyperopia — a  very  common  defect,  and 
possibly  a  very  serious  one  'from  the  stand-poiit  of  the  neu- 
rologist) if  allowed  to  go  unrecognized.  It  reveals  the  exist- 
ence of  a  previous  ciliary  spasm.  It  often  arrests  headache 
as  if  by  a  magic  touch,  and  solves  the  nervous  origin  of  many 
other  similar  symptoms."  * 

These  reflex  neuralgias  are  familiar  to  everybody 
who  has  known  headache  from  indigestion  or  from 
constipation.  The  disturbances  of  the  alimentary 
canal  are  reflected  upon  sensory  branches  of  the 
fifth  nerve;  here  relief  can  only  be  obtained  by  rem- 
edies which  correct  the  disorders  of  the  digestive 
tube.  I  know  persons  whose  "bilious  headaches"  (as 
they  are  called  in  the  older  terminology)  are  speedily 
remedied  by  an  emetic  of  ipecac  or  a  calomel  purge; 
others  can  only  keep  free  from  these  headaches  by 
rigid  dieting  and  some  mild  stomachic  and  aperient, 
like  the  infusion  of  rhubarb  and  cardamoms: 

(3     Rhubarb,  in  coarse  powder, 

Cardamom  seeds  (bruised),  aS  3  i. 
Aquse  ferventis,  J  viii. 
M.     Infuse   half  an  hour,  strain,  and  take  a  wine-glassful 
when  the  stomach  is  oppressed. 

Patho'ogy  is  full  of  instances  of  disturbances  of  function 
owing  to  a  morbid  irritation  in  a  distant  part  of  the  body. 
Thus,  the  irritation  oi  teething  sometimes  Lauses  convulsions. 


*  Ntiv  i'ori  Mtdical  Rtcorii,  Jan.  ai,  i8 


of 


on 
he 
nd 

fU- 

st- 
he 
ny 

dy 
im 

ry 

he 
li- 
ve 
as 

ily 

»^» 

by 

nt, 


ful 


ion 
ns, 


—  75  — 
and  a  prolapsed  uterus  has  been  known  to  cause  melancholia. 
Maudsley  thus  explains  this  reflex  transmission:  "A  molecu- 
lar change  in  the  interior  of  a  nerve  being  set  up  by  the  pri- 
mary irritation  *  *  *  is  carried  to  any  part  with  which  it 
ii  in  connection  by  continuity  of  nerve  structure;  when  the 
molecular  agitation  reaches  a  motor  centre  it  is  reflex  move- 
ment or  reflex  paralysis;  when  it  reaches  a  sensory  centre  it  is 
reflex  or  sympathetic  sensation;  when  it  reaches  the  supreme 
ideational  centres  it  may  occasion  reflex  disorder  of  thought, 
feeling,  and  will." 

Toxic  Neuralgias. — A  good  instance  of  neuralgia 
of  toxic  origin  is  the  hemicrania  which  sometimes 
attends  renal  insufficiency  and  uraemic  poisoning.  This 
kind  of  neuralgia  has,  however,  been  classed  by  some 
authorities  among  the  holopathic,  which  are  due  to  a 
general  morbid  state.  (See  Vanlair's  table).  Lead  colic 
is  an  obstinate  neuralgia  of  the  abdominal  walls  from 
lead  poisoning.  The  pain  ordinarily  starts  from  the 
umbilicus  and  radiates  through  the  entire  abdominal 
muscles.  It  presents  at  times  atrocious  paroxysms;  is 
ordinarily  accompanied  by  nausea,  vomiting,  and  con- 
stipation. The  treatment  is  by  calmatives,  purga- 
tives, and  iodide  of  potassium;  the  latter  favors  the 
elimination  of  lead  from  the  system. 

The  osteocopic  pains  of  syphilis  have  been 
classed  among  the  toxic  neuralgias.  Here  the  spe- 
cific treatment  alone  will  do  good;  small  doses  of  cal- 
omel, -^  grain  every  hour  for  a  day  or  two,  sometimes 
work  marvellous  results. 

Syphilitic  neuralgia  is  also  a  holopathic  neuralgia, 


Ill 


-76- 

according  to  Vanlair.  Rut  syphilis  is  attended  with 
palpable  lesions  which  cause  pain,  and  the  existence  of 
true  neuralgia  from  syphilis  has  been  disputed. 

Some  cases  of  neuralgia  from  mercurial  saliva- 
tion have  been  noticed.  Anstie  narrates  one  of  a 
young  girl,  who  not  only  lost  every  tooth  in  her  head 
and  suffered  extensive  exfoliation  from  the  maxillae, 
but  after  the  process  was  over  suffered  frightfully 
from  neuralgic  pains  in  her  arms  and  legs.  This  pa- 
tient got  better  under  tonics  and  cod  liver  oil,  but 
was  never  fully  restored.  In  neuralgia  from  abuse  of 
mercury,  it  is  found  that  iodide  of  potassium  in  as 
large  doses  as  can  be  borne,  and  continued  for  months, 
gives  the  most  relief. 

Neuralgias  from  alcohol,  tobacco,  arsenic,  and 
ergot,  have  also  been  noted;  these  agents  operate  not 
so  much  by  their  irritant  properties  as  by  bringing 
about  a  condition  of  malnutrition  and  dyscrasia. 

Under  the  head  of  toxic  neuralgias  might  also  be 
ranged  many  neuralgias  which,  like  the  neuralgias  of 
syphilis  and  Bright's  disease,  are  due  to  some  morbid 
material  in  the  blood  depressing  innervation  and  dis- 
turbing nutrition;  they  are  also  neuralgias  due  to  a 
general  morbid  state.    Thus  writers  have  spoken  of: 

I.  Gouty  Neuralgia.  Gouty  neuralgia  has  a 
predilection  for  the  viscera,  especially  for  the  gas- 
tro-intestinal  canal  (Vanlair),  and  for  the  .sciatic 
nerve.  These  neuralgias  sometimes  take  the  place  of 
the  regular  gouty  paroxysm  (having  thus  a  metastatic 


—  77  — 
character);  they  disappear  under  the  influence  of  an 
arthritic  attack  (gout  in  the  great  toe),  or  even  of 
a  cutaneous  eruption;  they  coincide  with  the  uric 
acid  diathesis;  the  exciting  cause  is  often  exposure  to 
cold,  even  an  unusual  dampness  in  the  atmosphere. 
These  neuralgias  are  benefited  by  calmatives,  by 
derivation  to  the  usual  seats  of  election  of  the  gout, 
by  alkalies,  by  colchicum,  by  drastic  purgatives,  and,  in 
short,  by  the  general  treatment  of  gout. 

2.  Rheumatic  Neuralgia.  It  has  been  customary 
to  regard  those  painful  attacks  which  are  consequent 
on  "  catching  cold  "  (as  when  a  person  is  exposed  to 
cold  and  wet,  and  has  severe  pains  in  the  muscles  of 
the  neck,  in  the  shoulders  or  back,  in  the  tract  of  the 
sciatic  nerve),  as  rheumatic  neuralgia.  Undoubtedly 
face-ache  and  migraine  are  often  excited  by  sitting  in 
a  draught.  There  is  much  obscurity  with  regard  to 
the  pathogeny  of  neuralgia  a  frigore,  as  well  as  of 
rheumatic  neuralgia  generally;  nor  is  even  the  partic- 
ular materies  morhi  of  rheumatism  yet  known.  Erb 
believes  that  in  these  rheumatic  neuralgias,  slight  in- 
flammatory conditions  of  the  neurilemma  are  com- 
monly present  (hyperaemia,  swelling,  exudations,  etc.) 
Eulenburg  states  that  neuralgia  caused  by  cold,  more 
frequently  attacks  the  sciatic  nerve  than  any  other,  and 
thinks  that  the  tendency  to  sciatica  is  characteristic  of 
the  relation  of  rheumatism  to  the  sensory  nerves.* 


•  Cited  by  Anstie. 


a9>r:M'!s!!S»WCe^ 


«<'l£d.*i.«UUA"%AV.iAdP^k^^LUw^'J: 


44 


I  IP 
'\  III 


li 


_  78  - 

To  justify  one  in  calling  any  particular  neuralgic 
attack  rheumatic,  he  would  have  to  show  a  history  of 
previous  rheumatism;  it  would  not  be  enough  to  mfer 
a  rheumatic  origin  from  the  fact  that  the  attack  fol- 
lowed exposure  to  cold  and  wet.  It  is  doubtful 
whether  rheumatism  or  the  rheumatic  diathesis  has 
any  very  frequent  causal  connection  with  any  form  of 

neuralgia.  . 

3  DiaMic  Neuralgia.— tieur&lgvd  has  some- 
times  occurred  in  instances  where  it  was  convenient 
to  trace  the  painful  affection  to  a  "  glyc-enuc  crasis 
of  the  blood,  and  whc.e  an  anti-diabetic  regimen  has 
alleviated  or  cured  the  pain.  Worms*  has  made  a  spe- 
cial study  of  this  neuralgia;  these  are  his  conclusions: 

(,)  There  exists  a  special  form  of  neuralgia 
proper  to  diabetes,  which  presents  for  its  character  a 
disposition  to  be  seated  in  the  two  symmetrical 
branches  of  a  same  nerve; 

(2)  Thus  far,  this  symmetrical  neuralgia  has 
been  chiefly  observed  in  sciatica,  and  in  the  inferior 

dental  nerve; 

(3)  Diabetic  neuralgia  appears  to  be  much  more 

painful  than  the  other  neuralgias; 

(4)  It  does  not  yield  to  the  ordinary  treatment 
of  neuralgias  (quinine,  morphine,  bromides,  etc.); 

(5)  It  is  aggravated  or  mitigated  coincidently 
with  the  aggravation  or  attenuation  of  the  glycaemia. 


I  f !' 


•  Vanlair,  loc.  cit.,  p.  309- 


i,a«aas#(»«^»l»a®!«S»r»*^'l^'^«®»*'''«*'' 


_ve«a<««WH»»^ 


IC 

)f 

;r 
il- 
ul 

EIS 

of 

e- 

nt 

I 

las 

)e- 

[is: 

B^ia 

r  a 

cal 

tias 
:ior 

ore 

ent 

(itly 
nia. 


—  79  — 

4.  Albuminuric  Neuralgia.— '\\\tve  is  probably 
no  disease  that  more  profoundly  modifies  and  vitiates 
the  blood  than  Bright's  disease  in  its  advanced  stages. 
Irritation  and  degeneration  of  the  nervous  centres  is 
certain  to  follow;  hence  the  stupor,  the  convulsions, 
the  obstinate  headaches,  the  amaurosis  of  chronic 
parenchymatous  or  interstitial  nephritis.  The  head- 
aches of  albuminuria  are  uraemic  (whatever  that  word 
may  mean);  they  are  generally  seated  about  the  brow 
or  vertex,  are  obstmate,  lasting  in  some  cases  five  or 
six  weeks  without  much  mitigation;  are  exasperated 
by  heat  and  light,  and  resist  all  ordinary  therapeutic 
means,  though  they  sometimes  yield  to  a  thorough 
depurative  treatment. 

5.  Zymotic  Neuralgias. — Obstinate  neuralgia 
sometimes  follows  the  acute  infectious  diseases,  and 
as  a  result  of  the  general  blood  poisoning  and  nerve 
degeneration.  Patients  convalescing  from  diphtheria, 
typhus,  yellow  fever,  cholera,  the  eruptive  fevers,  etc., 
besides  being  predisposed  to  the  ordinary  neuralgias, 
are  often  afflicted  with  severe  pains  of  a  very  peculiar 
and  puzzling  nature.  Such  was  the  case  of  a  young 
man,  a  private  patient  whom  I  last  year  attended 
during  an  attack  of  typhoid  fever.  The  disease  ran 
a  severe  course,  and  convalescence  only  came  on  about 
the  thirtieth  day  of  the  fever,  and  was  slow  and 
tedious.  This  patient  complained  of  pains,  some- 
times acute  and  shooting,  sometimes  dull  and  contin- 
ued, in  the  soles  of  his  feet.     These  pains  were  such 


/r 


—  80  — 
as  to  deprive  him  of  his  sleep,  and  morphine  injec- 
tions were  for  a  lonK  time  reciuired;  thty  eventually 
wore  off  with  return  of  health. 

Another  patient  whom  1  attended  in  the  Anna 
Jaques  Hospital  for  typhoid  fever,  had,  during  con- 
valescence, severe  pains  in  the  calves  of  tlie  legs. 

It  should  be  mentioned  in  this  connection,  that 
some  authorities,  as  Vanlair,  do  not  regard  these  ncu- 
ralgias  as  so  much  due  to  the  presence  of  bacteria  in 
the  blood  or  poisonous  ptomaines,  as  to  the  degenera- 
tive lesions  of  the  nervous  system  brought  on  by  long 
exhausting  illness. 

6.     Under  the  head  of  holopathU  neuralgias,  Van- 
lair classes  certain  mcstastatic  neuralgias  due  to  the 
abrupt  suppression  of  the  menses,  of  a  htemorrhoidal 
flux,  of  chronic  pulmonary  catarrh,  or  of  old  ulcers. 
He  might  have  added,  the  retrocession  of  a  cutaneous 
eruption.     I    myself  once  witnessed  the  supervention 
of  a  severe  hemicrania  in  a  woman  on  whom  1  had 
operated  by  ligature  for  bleeding  piles;  it  was  only 
after   some  months  of  rather  frugal  dieting,  and  the 
plentiful  use  of  Carlsbad  salts,  that  this  patient  ob- 
tained exception  from    headaches.      Barras  cites  a 
similar  case,  where  obstinate  gastralgia  followed  tht 
suppression  of  hamorrhoids. 

7.  Hysterical  Neuralgias  belong  to  the  same 
category  of  neuralgias  due  to  a  general  morbid  state. 
Hysteria  is  responsible  for  a  great  variety  of  neural- 
gic   affections,   ramicular,   visceral,   and    cutaneous. 


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Hysterical  neiiralj(ia  is  prone  to  take  on  the  hemi- 
cranial  form,  and  the  charaiteristic  (ion  hy.sUrii/iif  has 
lonjj;  attracted  the  attention  of  physicians.  Hysteri- 
cal neiiraljijias  iiave  a  marked  pretliliction  for  the  left 
side  of  the  body. 

These  neiiral>;ias  markedly  resemble  the  idiopa- 
thic, but  their  dependence  on  a  diaii\esis  just ilies  their 
classification  amons^  the  hoiopatiiic. 

8.  Chlorotic  and  Aiuemic  Neutal^ias. —  Neural- 
gia, according  to  Trousseau  and  Pidou.x,  "  is  an  al- 
most constant  symptom  of  chlorosis'" 

'I'he  three  forms  most  peculiar  to  this  morbid 
constitutional  state  are  headaciie,  gastralgia,  and  mus- 
cular aching;  the  latter  resembles  the  sensation  of 
fatigue  rather  than  muscular  rheumatism. 

It  is  in  these  cases  that  a  tonic,  fortifying  regi- 
men (exercise  in  the  open  air,  boating,  horse-back 
riding,  skatihg;  full  diet  consisting  of  meat,  eggs  and 
fats),  with  iron,  arsenic,  and  manganese,  sometimes 
works  wonders.  Attention  to  the  excretions  is  im- 
portant; iron  does  not  work  well  if  the  bowels  are 
constipated;  warm  baths  to  promote  the  cutaneous 
functions  followed,  as  the  patient  can  bear  it,  by  cold 
water  treatment,  may  be  important  adjuvants  to  a 
successful  medication. 

9.  Malaria  is  frequently  a  cause  of  neuralgia,  es- 
pecially in  regions  where  fever  and  ague  prevail.  The 
nerves  most  commonly  affected  are  the  supra-orbital 
branches  of  the  fifth.     A  distinct  feature  of  this  in- 


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—  82  — 
termittont  hrnw-ache  is  a  periodicity  of  the  attacks 
which  are  separated  by  intervals  of  complete  calm. 
The  type  is  tertian,  double  tertian  or  quartan,  al- 
though the  (luotidian  type  is  by  no  i-eaii!:  uncommon. 
It  is  in  this  kind  of  neuralgia  that  quinine  in  full  doses 
is  attended  by  the  happic  1  results. 

10.  £rf,'0tic  neuralgia  (from  eating  spurred  rye) 
has  been  witnessed  in  i.  rtain  parts  of  France.  The  ex- 
tremities (hands  or  feet)  are  affected  with  numbness, 
tingling,  darting  pains  (acrodynia  or  cheiropodalgia). 
it  is  doublful  if  this  affection  can  properly  be  called  a 
true  neuralgia. 


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i 


CHAPTER  VII. 


DIAGNOSIS, 

The  distinguishing  features  of  idiopathic  neural- 
gic pains  are:  i.  Their  frankly  intermittent  or  remit- 
tent character;  2.  The  suddenness  of  their  onset 
(Anstie  gives  as  an  example  the  sudden  and  violent 
neuralgic  pain  of  the  eyebrow  which  some  persons  ex- 
perience from  swallowing  a  bit  of  ice) ;  3.  The  limita- 
tion of  the  pain  to  a  definite  nerve  trunk  or  the  area 
occupied  by  its  terminal  branches,  and  its  generally 
unilateral  character;  4.  lihe points  douloureux -which 
occur  in  various  parts  of  the  tract  of  the  nerves;  5. 
The  various  motor,  vaso-motor  and  trophic  disturb- 
ances which  accompany  the  painful  phenomena,  and 
which  pertain  principally  to  the  area  of  distribution 
or  immediate  vicinity  of  the  nerve  or  nerves  affected; 
6.  The  absence  of  fever  or  other  marked  constitutional 
disturbance  and  the  signs  of  local  inflammation;  7. 
Finally,  the  characteristic  common  to  all  neuralgias, 
that  fatigue  and  every  other  depressing  influence 
directly  predispose  to  an  attack  and  aggravate  it 
when  already  existing  (Anstie). 

With  these  diagnostic  characteristics  in  mind,  one 
will  hardly  confound  an  ordinary  headache  from  in- 
digestion or  lithsemia  with  true  neuralgia,  for  the 
heavy  character  of  the  pain  in  the  former  instance, 
with  scarcely  any  tendency  to  ingravescence,  and  its 


■;aa«»6estfsw5»($sia>A«s«»i«j«s«;;i^8a«^«as»*^ 


_  84  - 
usually  bilateral  situation,  the.  nausea,  languor  and 
coated  tongue,  which  ordinarily  accompany  it  from 
the  first,  sufficiently  distinguish  it  from  migraine. 
Moreover,  these  attacks  of  gastric  headache  are  not 
periodical,  but  arise  from  some  error  in  diet,  and  not 
infrequently  from  catarrh  of  the  stomach.  It  is 
hardly  necessary  to  qualify  the  foregoing  remark  by 
the  statement  that  true  migraine  does  sometimes  find 
its  provok  ng  cause  in  dietary  indiscretions. 

Neuralgia  has  been  confounded  with  peripheral 
neuritis;  the  pathognomonic  features  of  the  latter,  ac- 
cording to  Nothnagel,  are  as  follows: 

1.  The  spontaneity  and  continuousness  of  the 
pain.  Paroxysmal  exacerbations  are  not  wanting, 
but  they  are  more  rare  than  in  neuralgia. 

2.  The  peculiarly  cyclical  course  of  the  attacks; 
the  pains  come  on,  and  disappear,  gradually. 

3.  The  constant  awakening  or  exasperation  of 
the  pain  under  the  influence  of  pressure. 

4.  The  cessation,  after  a  certain  time,  of  the 
pains  both  spontaneous  and  provoked.  (This  is  not 
properly  a  pathognomonic  sign  of  neuritis,  seeing 
that  it  is  met  with  in  other  aifectious  of  the  nerve- 
cords.) 

5.  The  centripetal  direction  of  the  spontaneous 

or  provoked  pain. 

6.  The  precocity  of  the  cutaneous  anaesthesia. 
7!     The  appearance  of  trophic  disturbances  in 

the  domain  of  the  nerve;  notably,  alterations  of  the 


t 


nd 
om 
ne. 
lot 
lot 
is 
by 
ind 

;ral 
ac- 

the 
ing, 

:ks; 

I  of 

the 

not 

eing 

rve- 

eous 

ia. 
IS  in 
the 


-  S5  - 

cutaneous  tegument  and  its  dependencies  (thickening 
of  the  skin,  herpes,  lesions  of  the  hairs,  nails,  etc.). 
Rapid  muscular  atrophy  would  have  almost  the  same 
significance. 

To  these  signs  (of  varying  value)  Vanlair  would 
add  the  following: 

((/)  The  more  circumscribed  and  direct  limitation 
of  the  pain— neuritis  limits  itself,  ordinarily,  to  a 
definite  nerve,  and  rarely  gives  rise  to  irradiations 
into  the  extremities  of  the  nerves;  (<!>),  the  fixedness  of 
the  seat;  (c),  the  absence  of  multiple  painful  points;  (</,) 
the  exaggerated  e.-ccitabilicy  of  the  di.seased  nerve — 
in  idiopathic  neuralgia  the  nerves  lose  their  electric 
sensibility;  (<?),  the  constant  appearance  of  troubles  of 
motility  (when  the  affected  nerve  is  a  mixed  nerve); 
(/),the  possibility,  in  some  cases,  of  feeling  the  swelling 
and  induration  of  the  nerve,  sometimes  even  of  per- 
ceiving a  reddish  streak  visible  at  the  surface  of  the 
skin;  (g),  the  very  constant  presence  of  a  traumatic 
cause,  of  the  local  action  of  intense  cold,  etc.;  (A),  the 
ordinary  absence  of  relapses,  while  relapse  is  the  rule 
in  neuralgias;  (/),  the  fever,  when  it  exists.* 

MvAi.GiA  (muscular  rheumatism)  is  the  pain  of 
over-fatigued  muscles— of  muscles  obliged  to  work 
when  imperfectly  nourished.  A  familiar  example  is 
the  stiff  neck,  or  lumbago  resulting  from  exposure  to 
cold,  an  accident  especially  likely  to  occur  when  the 


*Vanlair,  he.  cit.,  p.  q8. 


'•:^a»***i*«*W«l*ll*SiooiMa>M.:drJi».*»«^s»*^^^ 


=i;jct:.=-W.^.E?- 


—  86  — 
individual  is  enfeebled  by  work   and  is  perspiring; 
pleurodynia,  or  pain   in   the   intercostal   muscles,  is 
another  example  of  myalgia,  and  this  affection  is  often 
mistaken  for  pleurisy  by  the  laity. 

Bearing  in  mind  the  distinguishing  features  of 
neuralgic  pains  (before  given),  there  can  be  little  like- 
lihood of  confounding  neuralgia  with  myalgia.     One 
characteristic    of    myalgic    pains     s,   that    they  are 
materially  relieved  by  change  of  pos  ure  and  rest— by 
keeping  the  affected  muscles  in  a  position  of  full  ex- 
tension.    The  pains  can  be  easily  referred  to  the  area 
of  certain  muscular  groups;  and  if  there  are  any  ten- 
der points,  these  are  over  the  tendinous  origins  and  in- 
sertions of  the  muscles.    Myalgic  pains  are  aggravated 
by  movements,  and  occur  in  persons  of  no  neurotic 
tendency  as  often  as  in  the  neuralgic;  while  heredity 
has  no  marked  influence  in  their  genesis. 

Spinal  Irritation   may  be  looked  upon  as  a 
tnvelalgia,  i.  e.,  a  neuralgia  of  the  medullary  axis.    Be- 
ing, therefore, /^r  5^  a  member  of  the  group  of  neural- 
gias, its  diagnostic  features  need  brief  statement  here. 
These  consist  in  the  connection  of  certain  symptoms, 
or  groups  of  symptoms,  with  tenderness  in  particular 
regions  of  the  spine.    Thus,  when  the  region  of  ten- 
derness is  in  the  cervical  region,  there  are  symptoms 
such  as  headache,  nausea,  vomiting,  face-ache,  fits  of 
insensibility,  cough,  pains  in  the  upper  extremities, 
etc.     When  the  tenderness  is  in  the  cervical  and  dor- 
sal  region,  there  may  be,  in  addition,  pains  in  the 


is 
ten 

of 
ke- 
)ne 
are 
-by 
ex- 
irea 
ten- 
1  in- 
ited 
otic 
dity 

as  a 

Be- 

ural- 

tiere. 

oms, 

:ular 

ten- 

toms 

ts  of 

lities, 

dor- 

n  the 


-  87  - 

sides  and  in  the  stomach,  pyrosis,  palpitation,  and 
oppression. 

When  the  dorsal  region  is  the  seat  of  the  spinal 
tenderness,  there  will  be  pain  in  the  stomach  and  sides, 
cough,  oppression,  fits  of  syncope,  hiccough,  eructa- 
tions. With  tenderness  in  the  dorsal  and  lumbar  re- 
gions, in  addition  to  the  symptoms  of  the  foregoing 
group,  there  will  be  pains  in  the  abdomen,  loins,  hips» 
lower  extremities,  and  dysuria  and  ischuria.  With 
tenderness  in  the  lumbar  region  principally,  pains  in 
the  lower  part  of  the  abdomen,  testes  or  lower  extremi- 
ties, dysuria,  ischuria,  disposition  to  paralysis  of  the 
lower  extremities.* 

Pseudo-Neuralgias — The  pseudo-neuralgias,  as 
has  been  elsewhere  said,  owe  their  existence  to  some 
lesion  in  the  region  where  the  pain  is  located:  /.  e. 
they  come  on  after  a  wound  injuring  a  nerve  or 
nerves,  or  they  are  consequent  on  some  tumor,  as  a 
neuroma  or  a  malignant  growth,  a  congestion  or 
some  obscure  diathetic  condition.     The   intense  pain 


*  This  disease  was  first  identified  by  T.  P.  Teale  in  1829, 
"On  Neuralgic  Affections  Dependent  on  Irritation  of  the  Spinal 
Marrow,"  1829;  also  by  the  GriflSn  brothers  in  their  valuable 
monograph,  1844.  The  subject  is  well  presrnted  by  Hammond 
"On  Spinal  Irritation,"  Leisure  Library  Series,  1886.  The 
treatment  is  by  restoratives  and  rest,  nerve  sedatives  and  an- 
algesics; blisters  over  the  painful  points  are  highly  spoken  of. 
See  further,  Radcliffe's  article  in  Reynold's  System  of  Medi- 
cine. 


fe'?7i^^aM^e5a«^iar;£jj&ipggft5gate<agaSwgwg^B^<*ai(fe£ji^!a<^ 


?:-.^aQivc*^w-ir?,S5?5=aW«>--^.v' 


—  88  — 

that  accompanies  an  ophthalmia  or  ulceration  of  the 
cornea  belongs  to  this  category.  The  pains  of  con- 
gestion in  general,  whether  the  nerve  trunks  par- 
ticipate in  the  hyper?emia,  or  are  simply  pressed  upon 
or  stretched  are  of  this  nature.  The  pains  of  pneu- 
monia and  pleurisy,  of  hepatitis,  of  cystitis,  of  metritis, 
etc.,  where  not  due  to  actual  neuritis,  belong  to  the 
same  category.  There  is  a  rare  painful  affection 
called  by  S.  Weir  Mitchell  and  Lannois  ''angio-paialytic 
neuralgia  of  the  extremities  "  occupying  the  lower  ex- 
tremities, the  soles  of  the  feet  especially,  sometimes 
unilateral,  sometimes  bilateral,  which  should  also  be 
classed  under  this  head. 

The  pain  wich  attends   gangrene    is  another  in- 
stance of  the  kind. 

The  reverse  of  hyperjemia  or  fluxion,  namely  ex- 
treme anaemia,  causes  pain  quite  as  excruciating  as 
any  neuralgic  suffering,  and  no  better  example  can  be 
given  than  the  pain  following  embolism  of  an  import- 
ant artery. 

Wounds  of  nerves  (by  swords,  knives,  fire-arms, 
etc.)  cause  painful  neurites  which  are  sometimes  very 
intractable.  The  symptoms  of  neuritis  have  been 
given  above  and  need  not  here  be  repeated.  The 
ordinary  traumatic  neuralgias  appear  several  weeks 
after  the  lesion.  They  may  get  well,  or  persist  long 
after  the  cicatrization  of  the  wound.  They  sometimes 
so  resemble  the  essential  neuralgias  as  to  be  nearly 
if  not  quite  indistinguishable  from  them.      The  pains 


he 
in- 
ir- 
on 
su- 
ns, 
he 
on 
>tic 
sx- 
les 
be 

in- 

ex- 
as 
be 

jrt- 

ms, 
ery 
een 
rhe 
eks 
ong 
ines 
arly 
ains 


-  89  - 

are  of  the  same  lancinating  character,  and  there  are 
the  tender  points;  in  many  cases  there  is  an  intoler- 
able burning  sensation  (causalgia),  which  is  patho- 
gnomonic of  nerve  injury. 

The  trophic  and  motor  troubles  attending  trau- 
matic neuralgias  are  more  severe  and  persistent  than 
those  attending  essential  neuralgia  (hypertrophy, 
atrophy,  motor  paralyses),  The  epidermis  is  prone  to 
atrophy,  giving  the  appearance  known  as  "  glossy 
skin." 

It  is  not  necessary  to  dwell  on  the  pains  of  cancer 
which  can  offer  no  difificulty  in  diagnosis. 

With  regard  to  the  little  painful  tumor  called 
neuroma,  it  often  follows  amputation  of  a  limb,  the 
section  of  a  nerve,  and  it  is  attended  with  pain  of  a 
very  intense  and  persistent  kind.  There  is  generally 
anaesthesia  in  the  domain  of  the  affected  nerve,  and 
the  patient  complains  of  numbness.  Nothing  but  ex- 
cision of  the  morbid  growth  does  much  good. 

Those  painful  affections  of  the  joints  first  de. 
scribed  by  Brodie,  and  known  as  hysterical  arthro- 
pathies bolong  to  the  category  of  pseudo-neuralgias. 
Here  the  diagnosis,  as  in  the  true  hysterical  neural- 
gias, must  be  based  on  considerations  drawn  from  the 
presence  of  the  pathognomonic  \  -^ptoms  and  stig- 
mata of  hysteria  itself. 

If  visceral  neuralgia  be  susp^  <.ed,  the  physician 
will,  by  the  proper  means  of  exploration,  exclude  the 
presence  of  any  organic  disease. 


.3bflK^M^«mus2^^ii#^a^^  ^ 


i--^«a'rfB=H-^^%~Ji?WI£^I!i«  -JlrtwiT^V 


->?_•*-"  '-^i^'^-^^'.M/r 


_  90  — 

Cerrbral  abscess  m'x^hi  be  confounded  with  neu- 
ralgia of  the  head.  The  former  is  sometimes  a  sequel 
of  caries  of  the  internal  ear  and  purulent  discharge, 
the  result  of  scarlet  fever,  measles,  etc.,  in  childhood; 
may  follow  a  blow  on  the  head.  There  are  no  true 
*' points  douleureux,"  and  the  pain  does  not  completely 
intermit;  the  pain  is  fixed,  tenacious,  profound  and 
circumscribed;  there  are  no  well  localized  secretory 
or  vaso-motor  phenomena;  the  pain  is  usually  attended 
by  severe  psychical  and  motor  disturbances  (delirium, 
coma,  convulsions,  hemiplegia)  which  are  sufficiently 
characteristic  of  central  disease. 

It  might  be  easy  to  mistake  the  lightning  pains 
of  locomotor  ataxia  for  those  of  true  neuralgia,  but  in 
the  spinal  disease  there  are  symptoms  denoting  de- 
generation of  the  posterior  root-zones;  the  peculiar 
staggering  gait,  the  numbness  in  the  feet,  the  fre- 
quent impairment  of  sight,  the  suppression  of  the 
tendon  reflexes,  etc.  The  early  signs  of  locomotor 
ataxia,  especially  insisted  upon  by  Dr.  Marx  Karger, 
are,  besides  the  presence  of  a  cord  like  sensation 
around  the  waist,  numbness  of  the  lower  extremities, 
retardation  of  the  rate  conduction  of  sensations,  the 
difficulty  or  inability  of  balancing  the  body  when  the 
feet  are  placed  parallel  or  close  together  and  the  eyes 
are  shut  (Romberg's  symptom),  the  absence  of  the 
patellar-reflex,  and  the  want  of  reaction  of  the  pupil. 

As  genuine  neuralgia  may  be  the  result  of  alco- 
holism and  mercurial  poisoning,  .so  there  are  certain 


uel 

ge, 
id; 
rue 
ely 
ind 
Dry 
led 
im, 
itly 

ins 
in 
de- 
liar 
re- 
the 
tor 
:er, 
ion 
ies, 
the 
the 
yes 
the 
pil. 
co- 
:ain 


—  91  — 

pseudo-neuralgias  due  to  these  poisons  distinguish- 
able, according  to  Erb,  by  their  persistence,  their 
localization  in  symmetrical  parts  of  the  extremities, 
especially  in  the  vicinity  of  joints.  Krb,  while  ad- 
mitting that  syphilis  may  produce  true  neuralgia, 
regards  the  osteocopic  pains  of  syphilis  as  true 
organic  pains,  the  result  of  morbid  deposit  about 
nerves,  and  distinguishable  from  neuralgic  pains  by 
their  seat,  their  symmetrical  position,  and  their  noc- 
turnal exacerbations.* 

The  limits  of  this  treatise  will  not  allow  me  to 
enter  upon  the  vexed  question  of  the  diagnosis  of 
neuralgias  of  central  from  those  of  peripheral  origin, 
a  matter  concerning  which  we  have  still  few  fixed 
rules  for  our  guidance. 

As  for  the  diagnosis  of  those  neuralgiform  pains 
which  depend  on  an  appreciable  lesion  of  the  en- 
cephalon  or  cord,  the  following  characteristics  (given 
by  Vanlair)  will  aid  in  distinguishing  them  from 
idiopathic  neuralgias: 

I.  They  present  an  exceptional  obstinacy. 

3.  The  pain  is  sometimes  continuous,  sometimes  inter- 
mittent. In  the  latter  case,  it  often  manifests  itself  as  a  light- 
ning irradiation  which  does  not  follow  the  anatomical  tract  of 

any  nerve. 

3    It  presents   generally,  when  it  is  continous,  a  great 

fixedness. 

4.  These  pains,  unlike  ordinary  neuralgias,  occupy  a 
nerve  in  its  totality,  1.  e.,  the  trunk  of  a  nerve  and  all  its 


*Ziemssen's  Cyclop.,  Vol.  XI,  p.  64. 


-atliiittf-jOfe'  -->-  -.^iiro's^i^it^tgii^'^T:--^ 


—    02    — 

brao.ties.     We  have  an  example  in  the  case  of  neuralgia  nt 
the  triReminus  due  to  intra-cranial  tumor. 

5.  It  often  invades  little  \iy  little  other  nerved  whose 
origin  borders  on  that  of  the  nerve  primarily  involved. 

6.  Pressure  exercised  over  the  region  of  the  nerve  ce.itret 
corresponding  to  the  point  of  emergence  of  the  nerves,  often 
produces  a  very  severe  pain  extending  to  all  the  ramifications 
of  the  nerve. 

7.  Local  means,  i.e.,  all  those  applied  over  the  tract  of 
the  nerve,  are  inefBcacious.* 


*Vanlaif, /«r.  e/<.,p.«t. 


of 
ose 

ret 

ten 
oni 

t  of 


CHAPTER  VIII. 

PROGNOSIS, 

'I'he  prognosis  is  more  favorable  where  heredi- 
tary influence  is  absent  than  wiiere  it  is  present. 

'I'he  idiopathic  neiirainias  are  less  amenable  to 
curative  means  than  the  symi)tomatic  or  constitu- 
tional; the  latter,  whether  chlorotic,  syphilitic,  malar- 
ial, diabetic,  or  gouty,  get  well  or  improve  as  the  con- 
stitutional state  improves,  on  which  they  depend. 

The  toxic  neuralgias  will  be  likely  to  undergo 
attenuation  and  disappear  when  the  toxic  agent  which 
causes  them  ceases  to  act  or  is  eliminated. 

Neuralgias  accompanying  grave  cachectic  states, 
from  whatever  cause,  are  relatively  obstinate.  None 
are  more  intractable  than  those  of  the  decline  of  life 
and  of  old  age,  and  neuralgias  of  central  origin  are 
more  difficult  of  treatment  than  those  of  peripheral 
origin. 

It  can  hardly  be  said  that  sex  influences  the 
prognosis. 

Neuralgias  of  long  standing  with  frequently  re- 
peated attacks  are  among  the  least  curable. 

Hysterical  neuralgia  is  apt  to  be  very  obstinate. 

Neuralgias  of  early  life  are  relatively  benign. 

According  to  Gowers,  neuralgias  of  the  fifth 
nerve  are  more  intractable  than  all  others. 


"■wii  iVnTiii  ftAhiU    'wTw  HW'i .  iui  ■  ■  III  I  ii    •triBif"ir--rt  TK    i  ^'  r.  -  f f  r  *^<Bi»f'  J 


i^FXa^ilu^,  .t—^  ~t 


'1 


/-^ 


CHAPTER  IX. 

THE   TREATMENT  OF  NEURALGIA. 

PROPHYLACTIC    TREATMENT. 

Idiopathic  neuralgia,  like  other  neuroses,  is  a 
hereditary  disease.  The  ancestors  of  the  neuralgic 
subject— one,  or  more  of  them — were  either  neural- 
gic, or  were  sufferers  from  hysteria,  epilepsy,  or  some 
other  neurosis;  or,  the  parent  may  have  impaired  a 
naturally  good  constitution  by  intemperance  or  some 
other  vice,  and  so  entailed  on  the  offspring  thac  in- 
stability of  nerve-organization  which,  under  suitable 
provocation,  finds  expression  in  some  form  of  neu- 
ralgia. 

There  are,  of  course,  exceptions  to  the  rule 
that  neuralgia  is  a  hereditary  disease ;  children 
born  healthy  have  had  their  constitutions  under- 
mined by  insufficient  diet,  by  some  one  or  more  of 
the  diseases  peculiar  to  children  (as  scarlet  fever 
or  diphtheria),  or  even  by  precocious  addiction  to 
some  vice. 

Children  who  have  inherited  the  neuralgic  tem- 
perament should  not  be  allowed  to  study  too  hard  at 
school,  and  should  not  be  subjected  to  physical  tasks 
of  an  arduous  and  exhausting  nature.  Moderation 
in  all  things  should  be  the  rule.  Such  subjects 
are   unfitted   to  bear  a  strain.     At  the  same  time, 


IS  a 
ilgic 
iral- 
ome 
ed  a 
ome 
;  in- 
able 
neu- 

rule 
dren 
ider- 
e  of 
"ever 
n  to 

tem- 
rd  at 
tasks 
ation 
>jects 
time, 


I 


-  95  — 
they  should  be  required  to  be  much  in  the  open  air,  to 
indulge  in  invigorating  sports,  to  perform  gymnastic 
exercises  of  certain  kinds  which  can  be  borne  with- 
out too  much  fatigue,  to  practice  rowing,  horse-back 
riding,  and  swimming.  The  cold  bath  or  cold 
douche  in  the  morning  is  a  good  auxiliary.  All  these 
hygienic  measures  improve  the  circulation  and  develop 
a  strong  muscular  and  nervous  organization.  Hydro- 
therapy especially  toughens  the  integument  and 
prevents  the  frequent  occurrence  of  debilitating 
rheums. 

To  these  means  should  be  added  a  full,  generous 
diet  of  meat,  eggs,  fish,  milk,  cereals,  vegetables,  and 
fruits.  Very  many  cases  of  neuralgia  have  been 
traced  to  a  meager  and  insufficient  dietary.  When 
we  remember  that  neuralgia  is  essentially  a  disease 
of  malnutrition,  and  that  nerve  substance  is  a  con- 
f.'lomerate  of  richest  animalized  principles  (phos- 
phor! ^ed  oleo-albumen),  we  see  that  we  must  place  in 
the  foremost  rank  of  remedial  agencies  those  means 
which  improve  or  restore  the  nutritive  functions. 

Some  of  the  worst  forms  of  migraine,  prosopal- 
gia, etc.,  that  I  have  ever  seen  were  among  the  poor 
and  ill-fed.  For  delicate,  half-starved  children,  brought 
up  in  slums  and  crowded  tenement  houses,  there  «an 
be  but  little  hope;  out  of  these  breeding  places  of  dis- 
ease, come  the  multitude  of  the  hysterical,  the  neural- 
gic, the  nervously  shattered,  who  float  about  between 
the  hospital  and  the  alms-house. 


>.i«atefii*aa&:a»*SM;a8»iii5isws«rf^^s:c*saivi«^b.i*i»5K:4.%tiiiWr'^ 


^|-'--^,,;.---*l'VWrAV."JF'*.^J"-'^--'.i;5-**S^'.^-V 


,1 


-    96      - 

The  neuropathic  child  siioiild  be  taught  the  neces- 
sity'of  plenty  of  sleep.  Too  much  emphasis  cannot 
be  placed  on  this  requirement.  Eight,  even  ten  hours 
sleep  a  day  is  not  too  much.  'I'hose  predisposed  to 
neuralgia  should  be  compelled  to  go  to  bed  early- 
between  the  hours  of  nine  and  ten  every  night,  and 
all  evening  excitements  should  be  forbidden.  Among 
the  latter  should  be  mentioned  the  reading  of  dime 
novels. 

As  everything  that  favors  the  precocious  devel- 
opment of  the  passions  is  bad,  the  evil  influence  of 
corrupt  companions  is  to  be  deprecated  and  avoided 
by  every  possible  means.  It  is,  however,  a  matter  of 
great  difficulty  for  the  parent  or  guardian  always  to 
avert  such  influences,  for  the  cousin  or  class-mate  of 
the  moral  and  "  goody  "  sort  is  often  the  one  who  in 
secret  instils  the  poison  and  corrupts  the  nature  of 
the  child. 

Doubtless  the  evils  of  masturbation,  as  practiced 
by  children,  have  not  been  too  highly  painted.  The 
neuropathic  child  cannot  be  too  early,  too  earnestly, 
or  too  faithfully  warned  against  the  pernicious  effects 
of  this  vice. 

PROPHYLAXIS    IN    THE    ADULT. 

The  adult,  who,  by  faulty  organization,  by  de- 
bilitating influences,  by  previous  attacks  of  neuralgia, 
is  predisposed  to  this  neurosis,  demands  essentially 
the  same  prophylactic  hygiene  as  has  been  above  out- 


*4- 


—  97  — 

lined.  He  should  possess  some  liglit,  healthy  em- 
ployment, and  avoid  occupations  that  involve  arduous 
toil  and  great  anxiety.  Good,  nutritious  food  at 
regular  seasons  should  be  eaten,  and  alcoholic  and 
other  stimulants  eschewed;  the  neuralgic  should  also 
religiously  refrain  from  smoking.  These  patients  are 
prone  to  seek  excitement,  and  often  suffer  a  break- 
down in  consequence.  One  patient  with  whom  I  was 
acquainted,  used  invariably  to  experience  a  return  of 
her  megrim  after  going  to  an  evening  party  or  a  ball. 
Such  persons  are  uncommonly  vivacious  under  ex- 
citement, and  endure  well  the  strain  for  the  time 
being.  They  are,  however,  capable  of  using  up  in 
one  evening's  dissipation  all  their  reserves,  and  of 
bringing  their  nerve-centres  into  a  state  of  unnatural 
erethism  that  weeks  of  rest  may  not  calm. 

The  condition  of  these  sufferers  is  often  deplor- 
able. Of  fine  literary  and  resthetic  tastes,  they  can- 
not long  enjoy  reading,  artistic  pursuits,  etc.,  without 
paying  the  penalty  in  an  attack  of  severe  orbital  or 
supra-orbital  neuralgia.  One  of  my  acquaintances 
cannot  read  an  hour  consecutively  without  twinges  of 
pain  through  his  temples,  which  oblige  him  to  desist. 
He  regards  himself  as  shut  out  from  the  best  enjoy- 
ment of  life;  is  gloomy  and  suicidal.  Persons  of  this 
temperament  need  an  especially  fortifying  regimen; 
of  which  life  on  the  sea  (yachting),  in  the  woods, 
among  the  mountain.s,  with  absolute  freedom  from 
brain  work,  shall  form  the  principal  part. 

7  MM 


ft^«vwsafc^»*4««»<sif**^B«W»«S»31=»W-<-'»K»ii4^ftt£*^-^*7^S<»«>S8R3^ 


■r  "f 


1      H 


-     98     - 

Some  writers  (as  Vanlair  and  Anstie),  have  found 
excessive  religiousness  a  factor  in  the  genesis  of  neu- 
ralgia; but  doubtless  an  ardent  espousal  of  the  most 
gloomy  theological  beliefs  is  less  harmful  than  the 
indulgence  of  depressing  vices,  or  the  cultivation  of 
voluptuous  appetites. 

The  same  remarks  that  have  been  made  about 
sleep,  are  applicable  to  the  adult  neurotic,  who  should 
have  regular  habits  of  sleep,  and  whose  sleep  should 
be  long  and  sound.  If  he  happens  to  be  a  poor 
sleeper,  he  should  endeavor  to  woo  tired  Nature's 
sweet  restorer,  by  taking  much  exercise  in  the  open 
air,  and  especially  diverting  exercises,  by  cold  bath- 
ing in  the  morning,  and  the  warm  bath  just  before 
going  to  bed,  with  vigorous  shampooing  of  the  body, 
along  with  the  sipping  of  a  cup  of  hot  water  contain- 
ing some  mild  cordial,  as  spirits  of  lavender,  or  even 
a  little  Fluid  Beef;  this  is  far  better  than  re- 
sorting to  any  of  the  ordinary  hypnotics,  as  chloral 
and  sulphonal,  which  are  sure,  in  the  end,  to  leave 
the  nervous  tonus  damaged.  It  is  only  exception- 
ally that  I  would  allow  a  neuropathic  patient  to  apply 
to  any  of  the  so-called  hypnotics  for  relief.  Where 
a  small  dose  of  whisky,  or  a  glass  of  bitter  ale 
will  produce  refreshing  sleep,  this  is  safer  than 
chloral  or  a  narcotic.  Sometimes  it  makes  a  great 
difference  what  the  victim  of  insomnia  eats  for  his 
supper,  and  there  are  all  sorts  of  idiosyncrasies  in 
regard  to  this.     Some  persons  will   sleep  better  with 


found 
f  neu- 
:  most 
in  the 
ion  of 

about 
should 
should 
1  poor 
iture's 
;  open 

bath- 
before 

body, 
>ntain- 
r  even 
in  re- 
:hloral 

leave 
;ption- 

apply 
Where 
;er  ale 

than 

great 
■or  his 
sies  in 
r  with 


—  99  — 

a  full,  some  with  an  empty  stomach.  To  some  pa- 
tients your  best  prescription  is  a  supper  of  hominy 
and  milk;  to  others,  a  light  lunch,  or  cup  of  beef-tea 
on  going  to  bed;  a  full  dose  malt  extract. 

Above  all  things,  the  neuralgic  invalid  should 
have  a  mind  at  ease,  for  anxiety,  care,  worry,  over- 
mastering passions,  are  the  greatest  foe  to  healthful 
sleep. 

As  adjuvants  to  a  cure,  there  are  certain  tonic 
medicines  which  deserve  mention  here  :  Quinine, 
strychnine,  iron,  arsenic,  and  a  very  moderate 
amount  of  some  of  the  fermented  liquors,  wine  and 
beer.  To  the  anaemic,  iron  and  arsenic  are  especially 
useful;  a  good  combination  is  the  iron,  arsenic  and 
strychnia  pill,  furnished  by  a  number  of  our  pharma- 
cists. 

Fothergill's  pill  is  a  good  stomachic  tonic.  Its 
formula  is  as  follows: 

9     Acid  arseniosi,  gr.  j. 
Ferri  sulph.  excic,   l  ss. 
Pulv.  capsici,   3  j. 
Pil.  aloes  et  myrrh,  q.  s. 

M.     Ft.  pil.  No.  LX. 

Sig.     One  pill  three  times  a  day. 

A  pill  of  dried  sulphate  of  iron,  aloes  and  myrrh, 
I  grain  each,  sometimes  works  well  in  chlorosis  ac- 
companied with  constipation.  The  same  may  be  said 
of  the  well  known  sulphate  of  iron,  sulphate  of  qui- 
nine, and  sulphate  of  magnesia  mixture. 


—--J 


\  ? 


I     ,i 


■Ji 


100    

Or  five  minims  of  Fowler's  solution  may  be  asso- 
ciated with  ten  grains  of  bicarbonate  of  sodium  and 
five  of  potassio-tarf  ate  of  iron  in  a  fluid  ounce  of 
infusion  of  quassia;  this  dose  to  be  given  after  each 
meal. 

Arsenic  is  ene  of  the  best  anti-neuralgic  reme- 
dies that  we  pjssess.  According  to  Anstie,  it  is  es- 
pecially useful  in  the  visceral  neuralgias.  With 
arsenic,  cod-iiver  oil  may  often  be  conjoined  to  ad- 
vantage. More  satisfactory  results  will  be  obtained 
from  the  pure  oil,  when  it  can  be  borne,  than  from 
any  of  Ihe  emulsions,  of  all  of  which,  according  to 
my  experience,  patients  soon  tire.  Too  much  care 
cannot  be  taken  that  the  oil  shall  be  perfectly  sweet 
and  fresh. 

A  course  of  electric  treatment  (galvanism  pre- 
ferably to  Faradism),  sometimes  works  well;  both  by 
calming  the  erethism  of  the  nerve  centres,  and  pro- 
moting the  nutrition  of  the  latter.  The  electrical 
treatment  of  neuralgia  will  claim  especial  considera- 
tion in  another  chapter. 

Treatment  of  Diatheses  which  lead  to  Neural- 
gia.—^euxaXgxsi  is  sometimes  under  the  dominance 
of  a  diathesis,  such  as  gout,  chlorosis,  rheumatism, 
hysteria,  diabetes.  The  treatment  which  is  devoted 
to  the  diathesis  is  the  proper  treatment  of  the  neu- 
ralgia. 

Neuralgia  of  Toxic  Origin. — Neuralgia  may  be 
dependent  on  a  poison  in  the  blood;  lead,  mercury. 


*i~. 


lOI     

arsenic,  alcohol,  malaria.  Here  the  leading  indica- 
tions are  :  i.  To  suppress,  then  antidote,  then  pro- 
mote elimination  of  the  poison;  2,  as  far  as  possible 
to  protect  the  organism  from  the  effects  of  the  toxic 
agent,  and  palliate  symptoms  as  they  may  arise.  It 
is  evident  that  when  the  proper  antidote  can  be  ad- 
ministered, this  is  the  remedy  par  excellence  for  the 
neuralgia.  In  malarial  neuralgia,  for  instance,  qui- 
nine in  large  doses  is  indicated.  In  alcoholic  neu- 
ralgia, suppression  of  all  alcoholic  stimulants  should 
be  strictly  enjoined.  In  nicotinic  neuralgia,  tobacco 
should  be  abstained  from.  In  colica  pictonum,  the 
proper  treatment  of  lead  poisoning  will  also  cure  the 
neuralgia. 

Reflex  Neuralgias. — These  neuralgias  are  due  to 
a  localized  morbid  state  (of  the  uterus,  kidneys'  etc.) 
and  the  successful  treatment  of  the  suffering  organ 
will  cure  the  neuralgia. 

Surgical  means  of  cure. — Neurotomy,  neurectomy 
and  nerve  stretching  have  all  been  practised  for  the 
cure  of  intractable  neuralgia.  Nerve  stretching  has 
been  principally  applied  to  sciatica,  and  neurectomy 
(which  has  given  some  brilliant  results),  to  the  treat- 
ment of  prosopalgia. 

Treatment  of  Neuralgic  Paroxysms. — When  you 
are  in  the  presence  of  an  attack  of  neuralgia,  the  first 
thing,  of  course,  to  do  is  to  relieve  the  pain.  It  is 
desirable,  if  possible,  to  obtain  analgesia  without  re- 
sorting to  morphine.     In  many  of  the  neuralgias,  such 


Mt 


ti 


—    102    — 

as  migraine,  and  those  of  central  origin,  whether  idio 
pathic  or  symptomatic,  antipyrin  often  gives  speedy, 
marked  relief,  fifteen  grains  being  followed  by  com- 
plete disappearance  of  the  pain.  A  repetition  of  the 
same  dose  in  the  course  of  a  few  hours,  and  a  contin- 
uance of  this  treatment  for  several  days,  the  antipyrin 
being  given  often  enough  to  keep  the  pain  under  sub- 
jection, may  be  all  that  is  required,  the  patient  being 
as  far  as  possible  removed  from  the  reach  f)f  causal 
influences.  This  is  Germain  S^e's  treatment  of  the 
headaches  of  students,  headaches  which  often  oblige 
matriculants  to  suspend  study  for  weeks  or  months. 
Acetanilid,  in  half  the  dose  of  antipyrin,  may  be 
attended  with  an  equally  good  result,  and  the  same 
may  be  said  ol  phenacetin,  which  is  coming  into  gen- 
eral favor.  Lately  exalgin  has  been  well  spoken  of; 
it  has  been  praised  as  an  anti-neuralgic  by  Dujardin- 
Beaumetz  and  Bardet. 

I  must  express  my  own  partiality  for  phenacetin, 
which  I  have  found  hypnotic  as  well  as  analgesic. 

I  have  also  seen  good  results  from  acetanilid  in 
neuralgic  headaches.  In  cervico-brachial,  dorso-lum- 
bar,  and  sciatic  neuralgia,  I  have  seen  no  benefit  from 
any  of  these  new  remedies  except  phenacetin.  Citrate 
of  caffeine  and  guarana  are  remedies  from  which  much 
good  may  be  expected  in  hemicrania,  and  always  where 
the  pain  seems  to  be  the  consequence  of  nerve  tire. 
The  dose  of  caffeine  is  three  or  four  grains,  of  guarana 
twenty  grains. 


r  idio 
peedy, 
com- 
of  the 
ontin- 
tipyrin 
er  sub- 
being 
causal 
of  the 
oblige 
lonths. 
lay  be 
:  same 
;o  gen- 
ten  of; 
jardin- 

acetin, 
lie. 

lilid  in 
o-lum- 
it  from 
Citrate 
1  much 
i  where 
re  tire, 
uarana 


—  103  — 
The  following   prescription,  for  which    I   am  in- 
debted to  the  late   Dr.  George   M.  Heard,  has  given 
good  results  in  headaches  of  all  kinds: 

IJ     Cit.   caffein 

Carb.  ammon ^  Sj- 

Elixir  guaranic ^Ih 

M.    Sig.— A  leaspoonful  every  hour  till  the  pain  is  relieved. 

Some  of  my  patients,  delicate,  migrainous  patients, 
keep  a  bottle  of  citrate  of  caffeine  constantly  on  their 
toilet  tables;  a  frequent  resort  to  it  keeps  them  free 
from  headaches.  I  have  never  seen  any  harm  result 
from  the  continuous  use  of  this  drug. 

Bromo-pyrin  and  Bromo-caffeine  are  two  pro- 
prietary medicines  whose  efficacy  depends  on  the  an- 
tipyrin  and  caffeine  which  they  contain. 

Aconitine,  in  pills  of  ^^^  grain,  one  pill  every  five 
hours  till  the  supervention  of  the  physiological  effects, 
or  till  the  pain  disappears,  sometimes  has  a  charming 
effect  in  migraine  and  tic  douloureux. 

In  face-ache,  especially  when  due  to  a  decayed 
tooth,  the  tincture  of  gelsemium  in  five-drop  doses, 
every  two  hours,  is  often  followed  by  speedy  subsid- 
ence of  the  pain.  I  have  always  found  gelsemium  in 
this  dose  to  be  a  perfectly  safe  remedy. 

Some  practitioners  have  great  faith  in  a  full  dose 
of  quinine  (fifteen  grains)  in  neuralgias  of  the  peri- 
pheral nerves,  whether  due  to  malaria  or  some  other 
cause.  I  cannot  say  that  I  have  ever  found  this  alka- 
loid beneficial  in  neuralgic  paroxysms,  except  where 


.  a -asf»«»«:3w»*OTMwr»« 


—    104   — 

the  attack  was  clearly  of  malarial  origin,  dross' 
neuralgic  pills,  in  which  (luinine  is  combined  with 
aconite,  strychnine  and  morphine  are,  1  think,  chiefly 
of  use  as  a  pro|)hylactic  where  attacks  have  been  fre- 
quent. 

As  outward  applications,  chloroform  liniment, 
veratrin  ointment,  extract  of  belladonna  rubbed  up 
to  a  paste  with  water,  spreatl  on  cloth  and  applied 
over  the  seat  of  pain,  have  had  their  advocates.  No 
external  means  can  be  relied  on.  Anodyne  embroca- 
tions are  more  useful  when  the  pain  is  rheuinatic  than 
when  it  is  neuralgic. 

Hypnotizers  claim  to  have  accomplished  wonder- 
ful results  by  putting  the  neuralgic  sufferer  into  the 
hypnotic  sleep,  and  a.ssuring  him  that  the  pain  no 
longer  exists.  As  nothing  is  impossible,  i\ priori,  and 
all  things  are  to  be  believed  on  sufficient  testimony, 
we  have  now  adequate  warrant  for  a  certain  faith  in 
hypnotism  as  a  means  of  cure.  Hernheim's  book  on 
"Suggestion  as  a  Therapeutic  Agency"  contains  a 
number  of  instances  of  severe  neuralgic  and  neuralgi- 
form pains  cured  by  hypnotic  suggestion.* 

It  will  often  happen  that  none  of  the  above  means 


*  It  cannot  but  be  admitted,  however,  and  good  clinical 
authorities  are  coming  to  see  this,  that  the  frequent  repetition 
of  hypnotic  practices  is  lilsely  to  be  promotive  of  hysteria. 
Germain  S6e  declares  that  to  relieve  pain  by  hypnotism  and  to 
render  the  patient  hysterical  thereby,  is  to  cast  out  Satan  by 
Berlzebub. 


Lim'.'.-.l.!-WliyUi' 


ross 

with 

iefly 

fre- 

lent, 
I  up 
)lied 
No 
oca- 
than 

icler- 
the 
I  no 
and 
ony, 
h  in 
c  on 
ns  a 
algi- 

eans 

nical 
tition 
teria. 
nd  to 
in  by 


—  '05  — 
are  applicable  to  the  case  in  hand,  or,  if  tried,  they 
have  resulted  in  failure.  There  is  nothing  to  do  then, 
but  to  resort  to  a  hypoderniii  injection  of  morphine. 
The  tablet  triturates  of  the  pharmacists  aie  very 
handy  for  this  purpose.  The  commencing  doKe  should 
be  the  sixth  of  a  grain.  If  no  relief  is  obtained,  the 
njection  may  be  repeated  m  fifteen  niinut-js  or  half 
an  hour.  In  bad  cases  of  tic  douloureux,  migraine, 
visceralgia,  I  have  often  had  to  repeat  these  injections 
every  half  hour  until  a  grain,  a  grain  and  a  half,  and 
even  two  grains  have  been  administered.  Severe  pain 
creates  great  tolerance  of  morphine.  I  have  seen  a 
delicate  neurotic  girl  in  a  paroxysm  of  cervico-brachial 
neuralgia  bear  with  impunity  a  quantity  of  morphine 
introduced  subcutaneously  that  would  have  killed  a 
strong,  well  man.  There  is  not  the  same  tolerance  of 
atropine,  and  it  will  not  do  to  push  the  injections  of 
this  alkaloid.  If,  for  the  first  injection,  one  of  the 
morphine  and  atropine  tablets  be  used,  in  the  subse- 
quent injections  the  atropine  should  be  omitted.  The 
dryness  of  the  mouth  and  throat  that  follows  a  full 
dose  of  atropine  gives  the  patient  great  annoyance 
and  discomfort. 

For  ordinary  hypodermic  use  I  employ  a  solution 
of  morphine,  consisting  of  four  grains  of  sulphate  of 
morphine  to  a  fluidounce  of  cherry-laurel  water.  Of 
this,  a  hypodermic  syringeful  may  be  injected  with 
safety  to  an  adult.  The  cherry-laurel  water  keeps  the 
solution  from  spoiling. 


pi 
i\ 

i.i 


« 


—  106  — 

Inject  into  a  fleshy  part  of  the  arm;  there  is  no 
advantage  in  injecting  over  the  seat  of  the  pain. 

Deep  injections  of  chloroform  sometimes  as  effec- 
tually relieve  the  pain  as  morphine  injections.  For 
sciatica,  take  up  a  syringeful  of  pure  chloroform  and 
inject  it  the  depth  of  the  syringe-needle  into  the 
gluteal  muscles. 

Antipyrin  may  also  be  used  hypodermically.  Dis- 
solve eight  grains  in  a  hypodermic-syringeful  of  warm 
water,  and  inject  the  whole  into  a  fleshy  part  of  the 
arm  or  thigh.  Germain  S^e  highly  commends  this 
use  of  antipyrin. 


■(ii 


■     1\ 


'  1 


TfTPaM-^'*'-'-"'--' --'   'Mmimm'mmti^ 


IS  no 

;ffec- 
For 
and 

I   the 

Dis- 
Ararm 
r  the 

this 


CllAPTEk  X, 

APPENDIX. 

A  more  particular  mentliin  of  the  principal  agents  o«  the 
antl-neuralRlc  medication  seems  requif fil ;  they  will  be  contlder-d 
in  ihia  lupplement. 

I.     Narcotics. 

Theie  remedies  are  nerve-stupefiers.  If  they  fail  to  com- 
bat the  cause  of  the  neuralKia.  they  at  least  attenuate  the  pain- 
ful paroxysms  by  an  elective  action  on  the  sensory  centres, 
whose  .rethism  they  calm.  The  remedies  to  be  considered 
under  this  head  are  ;  Opium,  belladonna,  Indian-herap.  hyos- 
cyamus,  piscidia,  gelsemium,  and  aconite. 

OPIUM. 

Opium.— While  opium  is  not  the  btst  analgesic  for  neural- 
fflc  pains,  and  is  certainly  to  be  avoided  as  far  as  possible,  it  Is 
"he  most  powerful  antagonist  of  pain  that  we  possess,  and  after 
all  other  remedies  have  failed,  the  physician  is  obliged  to  fall 
back  on  this  incomparable  anodyne. 

Modt  of  Action.— 0\\\km.  is  a  true  protoplasmic  poison. 
In  proper  doses,  it  suspends  those  molecular  changes  on  which 
life  depends.  It  acts  on  the  cortical  cells  of  the  cerebrum  as  a 
stupefier,  dimlnlfhing  reflex  excitability  and  allaying  pain. 

Indications  and  Contra-indications.— In  all  the  ceret)ro- 
spinal  neuralgias,  opium  or  Its  alkaloids  may  be  indicated. 
Certain  idiosyncrasies,  however,  may  forbid  its  employ,  ai 
where  nausea  and  vomiting,  vertigo,  epigastric  anguish,  dys- 
uria.  attend  the  therapeutic  use  o(  any  opiate.  Some  patients 
are  so  prostrated  by  opiates  that  they  will  suffer  almost  any 
degree  of  pain  rather  than  resort  to  them.  .... 

According  to  Vanlair,  opium  Is  better  adapted  to  the 
treatment  of  the  visceralgiat  thau  the  cerebro-splnal  neuralgias, 
and  acts  better  in  lymphatic  than  in  nervous  subjects. 

Modes  of  Administration  and  /?w«.— Opium  may  be 
employed  externally  In  the  form  of  liniments,  ointments,  and 
plasters.  The  linimentum  opii  contains  equal  parts  of  lauda- 
num  and  opodeldoch.  The  emilastnum  opii  has  opiuns  and 
Burgundy  pitch.  In  the  French  Codex  Is  a  gWctntt  of  mot- 
pkia:  a  grains  of  morphia  to  an  ounce  ot  glycerin.  All  these 
may  be  used  for  local  effect,  or  the  aqueous  extract  may  be 


^1 


1^! 


Hi 


i  i 


H\\ 

IP 


( i; 

I- 

!    t 

I     I 
'1 

I! 


I   J 


—  io8  — 

rubbed  up  with  water  and  applied  in  compresses.  The  decoc- 
tion of  poppies  has  sometimes  been  used  as  a  local  anodyne. 
It  must  be  confessed,  however,  that  no  great  benefit  can  be 
obtained  from  these  external  applications. 

Crude  opium  is  seldom  given  internally  for  neuralgias, 
and  the  same  may  be  said  of  the  fluid  preparations.  The 
vinegar  of  opium  (English  black  drops)  has  a  certain  reputation 
in  gastralgia;  dose,  :o  drops. 

The  only  alkaloid  of  opium  deserving  of  mention  in  con- 
nection with  the  therapeutics  of  neuralgia,  is  morphine.  This 
alkaloid  may  be  g^ven  internally  in  ^he  dose  of  a  quarter  of  a 
grain,  every  hour  or  two,  until  the  pain  is  relieved.  The  bet- 
ter method  of  administration,  however,  is  the  hypodermic 
method.  One-fourth  grain  of  morph.  sulph.,  or  ten  minims  of 
Magendie's  solution  may  be  injected  into  the  cellular  tissue  of 
a  fleshy  part  of  the  arm ;  the  effect  will  be  far  more  speedy  and 
lasting  than  when  the  alkaloid  is  given  by  mouth.  Moreover, 
only  about  half  the  ordinary  dose  is  needed  when  the  morphine 
\f.  injected,  a  quarter  of  a  grain  thus  introduced  having  about 
the  same  effect  as  halt  a  grain  taken  by  the  mouth. 

Morphine  may  advantageously  be  combined  with  atro- 
pine for  hypodermic  use,  as  in  the  tablet  triturates  sold  by  the 
apothecaries. 

There  is  no  need  at  the  present  day  of  insisting  on  the 
advantages  of  hypodermic  medication;  all  practitioners  recog- 
nize the  superiority  of  this  method  over  every  other  when  it  is 
a  question  of  obtaining  the  maximum  of  effect  with  the  mini- 
mum dose. 

Nor  is  it  necessary  to  speak  of  the  endermic  method,  now 
superseded  by  the  hypodermic. 

Chlorodyne — Chloranodyne. — How  to  obviate  the  injurious 
after-effects  of  morphine  when  this  alkaloid  is  administered 
for  pain,  has  long  beer  the  study  of  physicians.  Experience 
has  taught  many  a  practitioner  that  the  combination  with 
aromatic  stimulants,  as  peppermint,  lavender,  cajaput,  was 
often  useful;  many  claimed  that  they  had  found  in  capsicum 
and  ginger  the  desideratum;  some  wanted  the  advantage  of  a 
union  of  the  opiate  with  alcohol,  chloroform,  or  various  nar- 
cotics and  sedatives,  such  as  belladonna  and  hydrocyanic  acid. 
When  I  was  an  interne  of  the  Montreal  General  Hospital,  in 
1864,  Collis  Browne's  chlorodyne  was  much  in  vogue.  Al- 
though its  composition  was  uuknown,  no  one  doubted  that  the 
active  anodyne  ingredient  of  this  preparation  was  morphia. 


ecoc- 
iyne, 
m  be 

Igias, 

The 

at  ion 

I  con- 
This 
of  a 
;  bet- 
Brmic 
ms  of 
>ue  of 
y  and 
over, 
phine 
ibout 

atro- 
y  the 

n  the 
ecog- 
1  it  is 
mini- 

,  now 

rious 

itered 

ience 

with 

was 

iicutn 

of  a 

nar- 

acid. 

al,  in 

Al- 

U  the 

phia. 


n 


—  109  — 

In  my  subsequent  private  practice  I  was  much  in  the  custom  of 
resorting  to  this  chlorodyne  (notwithstanding  its  high  cost) 
when  obliged  to  give  morphia  to  patients  who  were  in  the 
habit  of  experiencing  unpleasant  results  from  the  drug  when 
given  alone.  I  found  it,  however,  an  uncertain  preparation, 
apt  to  spoil  by  precipitation  of  the  molasses,  which  was  the 
vehicle  of  the  active  ingredients:  and  about  seven  years  ago  I 
abandoned  the  Collis  Browne  Chlorodyne  for  Oilman's,  the 
formula  of  which  I  found  in  the  Boston  Medical  and  Surgical 
Journal. 

Q    Chloroform,  J  ij. 

Glycerine.  Jii. 

Alcohol,  Jii. 

Spts.  peppermint,  i  ij. 

Acid  hydrocyanic  dilute,  3  ij. 

Tincture  capsicum,   Jij. 

Morph.  sulph.,  gr.  viii. 

Syrup,  iiii. 
M. 

The  dose  of  this  preparation  for  an  adult  is  one  teaspoon- 
ful,  which  contains  one-eighth  grain  morphia. 

The  above  combination  is  a  good  one,  the  ingredients 
being  all  held  in  solution,  and  the  taste  being  far  less  un- 
pleasant than  the  nasty,  tarry-looking  compound  generally  sold 
under  the  name  of  chlorodyne. 

Despite  the  fact  that  I  have  long  used,  and  almost  daily 
in  my  practice,  the  Oilman  chlorodyne,  I  find  in  the  prepara- 
tion devised  by  Parke,  Davis  &  Co.,  and  sold  under  the  namt 
of  Chloranodyne,  a  more  eflScient  and  elegant  combination.  I 
do  not  hesitate  to  say  that  nothing  as  yet  made  is  quite  so  sat- 
isfactory. The  dose  is  about  the  same  as  the  old  Collis 
Browne  article,  while  the  action  is  more  certain.  The  small- 
ness  of  the  dose  (15  to  20  drops)  is  an  advantage  over  the  Gil- 
man  chlorodyne,  which  must  be  given  in  drachm  doses  and  is 
about  equally  expensive. 

The  formula  of  Parke,  Davis  &  Co.'s  chlor-anodyne 
•hows  each  gramme  to  contain  the  following  ingredients  in  the 
quantities  indicated: 

B    Morphia  muriate oo£o  grm. 

Tinct.  Cannab.  Ind 0800  grm. 

Chloroform 1350  grm. 

Oil  of  peppermint ooas  grm. 

Tinct.  capsicum ooasgrm. 

Hydrocyanic  acid  dilute 0170  grm. 

Alcohol socogrm. 

Glrcerine 4570grm. 


r' 


ri 


h 


n 


I  > 


•41 


it   i 


IIO    

BELLADONNA. 

"The  antl  neuralgic  action  of  belladonna,"  says  Van- 
lair  "is  not  dependent  on  its  physiological  effects,  for 
belladonna  is  an  excitant  of  the  central  eel  s.  and  us  stu- 
pefying properties  do  not  appear  till  after  an  intense  and  pro- 
looled  excitation.  If  we  were  to  consider  pain  as  a  simple 
exaltation  of  the  sensibility,  the  efficacy  of  be  ladonna  in  the 
treatment  of  neuralgias  would  be  absolutely  inexplicable.  * 
r*r  But  pain,  not  being  hyperesthesia,  there  s  nothing  to 
prevenrbelladokna,  even  when  it  does  not  exert  'ts  stupefying 
Properties,  from  acting  against  the  algesic  element  and  tri- 
Smohing  over  it.  Belladonna  is  even  superior  to  opium  in  cer- 
uTn  respects  It  not  only  manifests  an  incontestable  <,»^<(y«* 
a*t"on  but  it  also  exerts  anti-neuralgic  properties  which  opium 
does  not  possess  to  the  same  degree .  ^  „    .  ..„ 

Vanlair  thus  expresses  his  preference  for  belladonna  over 
the  oUier  narcotics  as  an  anti-neuralgic.    arid  whatever  we 
mav  think  of  his  explanation  he  here  seconds  views  before 
.fL-5    h«   Rehier    Courty,    and  Trousseau      The   kind    of 
SeuralKias^Wch   he^r^^^^^^^^    most    amenable    to  belladonna 
are    "£  idiopathic,    and  especially   those  affecting    nerves 
olaced  superficially.     Such  are  the  facial  neuralgias,  and  es- 
SIhaIIv  those   of    the  supra-orbltal  branches;  the  tempora 
SeSeias  yfeld  equaUy  well,  but  neuralgias  of  the  infra-orb.tal 
StrvesCmoresmbborn."    *    »    *    l""  '^l^T:.''^^^^ 
Affections,  he  would  rely  much  on  local  applica  ions  of  bella- 
donna    The  dose  of  the  alcoholic  extract  and  the  powder  of 
the  "eaves  is  one-fourth  of  a  grain  twice  or  three  times  a  day. 
Outward  applications  over  Painful  regions  of    the  extra« 
rubbed   up  with  water,  or  of    cataplasms  of  ^he  leaves    are 
^metimes  of  unquestioned  efficacy.     Trousseau  counselled  to 
mlie  a  oLte  of  the  extract  with  a  few  dropsof  water,  and  rub 
uSer^the  painful  part.     He  has  found  this  treatment  ol 
efficacy  in  sciatica.     Vanlair  prefers  an  ointment  made  by  nib- 
bing up  half  a  drachm  to  a  drachm  of  ex.ract  of  belladonna  in 
an  ounce  of  lard,  vaseline,  or  glycerite  of  starch.  ^„^^,.  „ 

r^uss,au'srrfaimen(o/Migrain,.-Hc  makes  a  quantity 
of  Dills  of  the  extract  of  belladonna,  each  containing  one- 
sUth  of  a  gratnl  one  of  these  is  given  every  hour  (cautiously) 
tin  the  complete  disappearance  of  the  pain,  or  till  some  vertigo 

'"  ^'^'Xtropine.   the  alkaloid  of  belladonna,   has  been   much 


i! 


an- 
for 
itu- 
»ro- 

iple 
the 

« 

;  to 
ing 
tri- 
cer- 
iyne 
ium 

>ver 

we 
fore 
I  of 
>nna 
rves 
I  es- 
toral 
bital 
p.lgic 
ella- 
:r  of 
day. 
ract, 
,  are 
ed  to 
Irub 
nt  ot 

rub- 
na  in 

intity 

one- 

)usly) 

srligo 

much 


—  Ill   — 

given  in  neuralgia.*  The  dose  would  be  one-hundredth  of  a 
grain,  which  should  not  be  repeated  more  than  three  times  in 
the  twenty-four  hours.  Atropine  is  preferably  given  by  the 
hypodermic  method;  one  of  the  rk  g™*"  '?b>et  triturates 
being  dissolved  in  fifteen  drops  of  water  and  mjected  subcu- 
taneously.  I  n  obstinate  idiopathic  cerebro-spinal  neuralgias  it 
will  not  do  to  rely  on  this  alone;  the  atropine  works  more 
speedily  and  effectually  if  combined  with  morphine.     Thus: 


9 


M 


Sulphate  of  morphine,  K  grain. 
Liquor  atropia,  a  drops. 
Cherry  laurel  water,  »o  drops. 
For  one  hypodermic  injection. 


Or  the  tablet  triturates  may  be  employed.     Each  contains 
one-fourth  grain  of  morphia,  and  one-hundredth  of  atropia. 

It  is  hardly  necessary  to  add  that  belladonna  is  not  in 
quite  the  same  repute  in  which  it  was  held  some  years  ago. 
before  the  antithermic  analgesics  and  caflft  *e  were  introduced 
into  therapeutics.  The  dose  both  of  belladonna  and  of  its 
alkaloid  required  for  the  complete  relief  of  pain  can  hardly  be 
regarded  as  a  perfectly  safe  dose;  at  any  rate  this  powerful  drug 
demands  skilled  and  experienced  management  for  its  succec.^- 
ful  employ. 

CANNABIS  INDICA-{HASHISH-INDIAN   HEMP.) 

Indian  hemp,  much  inferior  to  opium  as  an  analgesic, 
has  been  found  serviceable  in  some  cases  of  migraine.  Ring- 
er declares  that  no  single  drug  has  been  found  so  useful  in  this 
common  neuralgic  affection.  It  should  be  given  for  weeks 
and  even  months  in  doses  oiyixo  %  grain  twice  a  day. 

Greene,  an  English  practitioner,  was  one  of  the  first  to 
make  of  hashish  a  sort  of  specific  against  migraine.  He  gave 
of  the  alcoholic  extract  of  Indian  hemp  from  0.02  to  0.03 
ex  to  \i  grain)  before  each  meal;  after  several  weeks  he  in- 
creased the  dose  somewhat,  and  continued  the  treatment  for 
three  months.  It  is  especially  in  the  migraine  of  young  peo- 
pie  that  Indian  hemp  does  good.  ,     ,      ..  o     ^ 

Seguin,  in  the  Medical  Record  (vol.  xii,  p.  774.  "77), 
recommends  the  same  treatment,  and  insists  that  the  doses 
shall  be  given  with  the  greatest  regularity.     The  principle  is 


♦According  to  Anstie,  atropine  is  particularly  useful  in  glaucomatous 
neuralgia,  and  in  neuralgia  of  the  pelvis. 


;i 


112    

to  keep  the  nervous  system  steadily  under  a  slight  influence  of 
cannabis  (or  a  long  period  of  time.  He  says  that  cannabis  is 
nearly  as  efficacious  in  migraine  as  the  bromides  are  in  epi- 
lepsy. Male  patients  can  generally  begin  with  half  a  grain, 
and  it  is  well  to  give  them  three-quarters  of  a  grain  in  two  or 
three  weeks. 

Lothrop,  in  a  paper  read  before  the  Buffalo  Medical  Club 
(Medical  Record,  vol.  xix,  p.  99),  advocates  Greene's  and 
Seguin's  method.  It  is  stated  as  a  matter  of  course,  that  at 
first  no  appreciable  effect  is  observed,  and  that  not  until  the 
use  of  the  remedy  is  persevered  in  for  many  weeks  will  the 
patient  find  a  decided  diminution  in  the  severity  and  fre- 
quency of  the  attacks  Lothrop  gives  a  fourth  of  a  grain  of 
the  alcoholic  extract  before  each  meal  for  the  first  fortnight, 
then  a  third  of  a  grain  for  the  second  fortnight,  to  be  aug- 
mented to  half  a  grain  at  the  end  of  four  weeks.  Corrigan  re- 
ports favorable  results  from  tincture  of  Indian  hemp  in  tic 
douloureux;  he  employs  the  tincture  in  the  dose  of  8  to  30 
drops. 

HYOSCYAMUS. 

This  narcotic  agent  is  little  employed  in  neuralgia,  the 
analgesic  effects  obtained  from  safe  doses  of  the  various  phar- 
maceutical preparations  of  henbane  being  too  feeble.  Meg- 
lin's  pills,  which  have  considerable  repute  in  neuralgia  contain 
extract  of  hyoscyamus.     The  composition  is  as  follows: 

Q    Oxide  zinc, 
Ext.  valerian, 
Ext.  hyoscyamus,  'li  Rr.  j. 

For  one  pill.    To  be  given  three  times  a  day. 

Hyoscyamus  leaves,  bruised  and  steeped  and  applied  as 
a  cataplasm  to  the  skin  in  superficial  neuralgias,  have  been 
vaunted  by  Trousseau  and  Pidoux. 

coNiuM  maci;latum. 

The  same  remarks  are  applicable  to  conium  or  hemlock. 
The  succus  conii,  however,  anciently  had  a  reputation  for  the 
cure  of  tic  douloureux,  in  the  dose  of  30  drops  three  times  a  day. 
The  conium  plaster,  and  cataplasms  of  hemlock  leaves  have 
been  recommended  for  outward  application. 


e  of 
s  is 
epi- 
ain, 
)  or 

:iub 
and 
t  at 
the 
the 
fre- 
1  of 
ght, 
»ug- 
I  re- 
I  tic 
3  30 


the 

ihar- 
Aeg- 
I  tain 


d  as 
been 


lock, 
r  the 
day. 
have 


—    "3  — 

STRAMONFUM. 

The  leaves  of  stramonium  have  been  similarly  used  as  an 
application  to  painful  parts.  A  good  way  is  to  mix  a  quantity 
of  the  dried  and  pulverized  leaves  with  the  ingredients  of  an 
ordinary  poultice. 

PISCIDIA  F.RYTHRINA. 

This  plant  is  known  under  the  name  of  Jamaica  Dogwood. 
Introduced  into  medicine  as  a  hypnotic  and  narcotic,  it  ha» 
been  found  to  possess  analgesic  properties  similar  to  gelsemium. 
It  is  especially  in  rebellious  facial  neuralgias  that  it  has  been 
prescribed. 

Preparation  and  doses. — The  fiuid  extract  is  alone  pre- 
scribed in  the  United  States,  in  the  dose  of  a  teaspoonful. 

CJKLSEMIUM  SEMPERVIRENS. 

This  plant,  known  as  the  yellow  jasmine,  has  real  analgesic 
properties,  and  has  been  especially  useful  in  facial  neuralgias 
and  in  hemicrania.  Perhaps  its  efficacy  is  more  marked  in 
dental  neuralgia  than  in  any  other  form  of  pain.  Gelsemium 
is  a  direct  paralyzerof  the  sensory  conductors  in  the  cord. 

A  severe  case  of  cervico  brachial  neuralgia  which  came 
under  my  observatioa  in  1876-1877  was  markedly  benefited  by 
this  drug.  On  numerous  occasions  I  saw  violent  paroxysms 
yield  to  five  drop  doses  of  a  saturated  tincture.  This  patient 
(a  young  lady  of  highly  neuropathic  organization)  was  kept  in 
comparative  comfort  for  more  than  a  year  by  the  gelsemium. 

The  dose  is  from  2  to  10  drops  of  a  saturated  tincture,  or 
of  the  fluid  extract,  which  may  be  cautiously  repeated  every 
hour  or  two  till  abatement  of  the  pain  is  produced. 

ACONITE. 

We  do  not  believe  that  aconite  in  the  form  of  tincture  or 
extract,*  is  of  much  service  in  neuralgia,  but  there  is  no  doubt 
as  to  the  utility  of  its  active  principle  aconitia. 


*  The  extract  of  aconite  is,  however,  a  principal  ingredient  o(  the 
tomewhat  famous  neuralgic  pills  of  the  late  Professor  Gross,  of  which  the 
formula  is  as  follows: 

B    Bxt.  aconite,  V-  H- 
Quinite  sulph.,  gr.  ij. 
Acid  arsenics,  gr.  i-ao. 
Strychnia,  gr.  t-  20. 

Morphia,  gr.  i-ao.  ^ 

M.     One  pill. 

8  MM 


•1 


u 


.1 


I    'f 


1 


\  m 


—  114  — 

Aconitia  (which  exists  in  the  root  of  the  aconitum  napellus 
in  the  proportion  of  about  one  drachm  to  twenty-six  pounds) 
has  been  made  the  subject  of  special  study  by  the  late  Prol, 
Gubler  whose  monographs  on  this  medicament  are  of  great 
practical  utility.  Gubler  was  one  of  the  first  to  msist  on  the 
importance  of  this  remedy  in  the  treatment  of  trigemmal  neu- 

'-tf;  Aconitia  is  found  in  commerce  under  two  distinct  forms; 
the  amorphous  and  the  crystallized.  The  latter  which  is  some- 
what stronger  and  more  reliable,  is  the  best  known,  and  is 
generally  prescribed  under  the  name  of  Duquesnel  s  afonitia. 
Not  to  dwell  on  the  toxic  effects  of  this  powerful  alkaloid, 
which  is  only  safe  in  very  minute  doses,  we  may  sum  up  its 
therapeutical  actions  by  the  observation  that  it  seems  to  have 
a  special  selective  influence  on  the  extremities  of  nerves  01 
sensation,  which  it  paralyzes.  This  elective  affinity  is  especi- 
ally  manifest  in  the  case  of  the  fifth  pair  of  nerves. 

The  beneficial  effects  of  this  medicament  in  neuralgia,  in 
facial  neuralgias  in  particular,  have  been  attested  by  a  multitude 
of  observers,  among  whom  we  may  mention  Oulmont,  S>eguin, 
Franceschini,  Merck,  and  Laborde.* 

Gubler  is  fond  of  narrating  an  incident  which  occurred  In  ms 
practice.  It  concerned  a  patient  on  whom  N61aton  had  prac- 
ticed  resection  "of  all  the  branches  of  the  trifacial  (!).  The 
pains  continued  to  be  just  as  atrocious  and  jiist  as  persistent 
as  ever  The  patient,  reduced  to  despair,  and  ready  to  com- 
mit suicide,  was  treated  by  Gubler  with  aconitia.  Seven  milli- 
erammes  a  day  of  Hottot's  aconitia  were  administered  m  gran- 
ules with  the  most  marked  relief,  and  by  perseverance  m  this 
remedy  a  complete  cure  was  effected. 

Laborde,  in  the  Journal  dt  Therapeutigue^^^\>\\%\^K^  re- 
ports  of  sixcasfsof  reur-lgia  mostly  of  the  fifth  pair,  mall 
of  which  marked  benefit  was  received  from  aconitia:  in  some 
the  benefit  was  permanent.  In  all  these  cases  the  medicine 
was  given  by  mouth.  He  makes  use  of  the  granules  of  Du- 
quesnel, containing  one-fourth  of  a  milligramme.  One  gran- 
ule is  a  sufficient  commencing  dose,  and  he  advises  that  the 
dose  should  not  be  repeated  under  four  houis.  'Generally  t"* 
second  granule  will  give  relief,  if  the  first  fails  to  benefit. 


•See  especially  the  exhaustive  articles  of  Laborde  in  the  Journal  dt 
ThtrafentiqutyiSiA  Tribunt  Mniical*,  1881. 


pellus 
>unds) 
Prof, 
great 
>n  the 
1  neu- 

forms; 
some- 
and  is 
onitia. 
<aloid, 
up  its 
)  have 
ves  of 
especi- 

jia,  in 
iltitude 
Seguin, 

1  in  his 
I  prac- 
.  The 
rsistent 

0  com- 
n  milli- 

1  gran- 
in  this 

hes  re- 
r,  in  all 
n  some 
[edicine 
of  Du- 
le  gran- 
that  the 
illy  the 
it. 


ntmal  dt 


—  "5  — 

A  safe  and  efficient  way,  which  we  have  often  tried,  is  the 
following,  which  is  in  accordance  with  the  directions  laid  down 
by  Dujardln  Beaumetz:  Duquesnel's  aconitia  is  ordered — the 
one-fourth  of  a  milligramme  granules.  Of  these  the  patient  is 
ordered  to  take  one  granule  every  three  hours,  till  eight  have 
been  taken  during  the  twenty-four  hours.  It  is  seldom  that 
there  is  any  occasion  to  go  any  further.  Generally  the  second 
or  third  dose  causes  complete  disappearance  of  the  pain.  Given 
in  this  way,  we  do  not  exceed  two  milligrammes  a  day.  If  this 
dose  not  not  relieve,  it  is  vain  to  push  the  remedy  further. 
Sometimes  after  the  second  or  third  granule,  a  little  tingling  of 
the  tongue  and  pricking  of  the  skin  of  the  face,  with  constric- 
tion of  the  mouth  are  experienced.  Patients  sometimes  com- 
plain that  their  head  feels  "  hoop-bound  "  for  a  time. 

There  is  no  doubt  about  the  superlative  excellence  of  this 
medicament  in  all  so-called  congestive  neuralgias,  and  we  have 
notes  of  obstinate  cases  of  sciatica  which  have  proved  amen- 
able to  treatment  by  aconitia.  It  is  one  of  the  remedies  that 
should  be  first  tried  in  severe  sciatica  and  \<yaCaaL%oaftigore. 

Even  in  the  case  of  symptomatic  facial  neuralgias,  as 
well  as  protopathic,  the  pain  is  often  alleviated  by  aconitia,  as 
Laborde  has  shown.* 

II.    Anaesthetics. 

The  only  ansethsetics  that  will  be  here  mentioned  are 
chloroform,  ether,  nitrite  of  amyl,  chloral,  cocaine,  bromide 
of  potassium,  and  menthol. 

These  remedies  abolish  sensibility,  but  their  action  is 
fugacious,  and  temporary,  therefore  they  are  only  to  be  resorted 
to  as  palliatives,  and  as  adjuvants  to  the  other  analgesics. 


*  From  an  article  by  the  author  iu  the  Mtdical  Rtcord^  July  14,  1883. 
The  foUowing  formule  are  taken  from  Uie  Formulairt  Pratique^  by  Du- 
jardio-Beaumetz: 

3 


Liquor  Aconitia  (Tumbull), 
Amorphous  aconttina,  1  gramme  (15  grains). 
Alcohol,  8  grammes  ( 3  iij. 
For  frictions  over  the  face  in  prosopalgia. 


9    Sulphate  quinine,  o  gr.  30  centigraames, 

Crystalized  nitrate  of  aconitia,  o—  ^  milligramme, 
Ext.  cinchona  q.  s.  for  one  pill. 

Take  one  to  three  of  these  pills  in  the  34  hou  '• 


r-r 


ii 


I' 


i;i 


—   ii6  — 

Chloroform,  ^/A^n— Anaesthetics  sometimes  «««»er  "r- 
vice  in  alleviating  the  violence  of  nfuralgir  pafo^y*""^-  ,  J''*" 
are  cases  where  every  remedy  seems  to  fail;  the  ?»"«"»''' 
racked  with  an  atrocious  migraine,  tlc-douleureux.  or  cervico- 
brachlal  neuralgia.  Morphine  has  been  «?•*"  hypoder- 
mlcally  up  to  the  point  of  danger,  or  very  near  to  this  point, 
"nd  stu"  the  persistent,  boring  pain  continues,  with  frequent 
stabs  and  darts,  and  the  poor  patient  can  get  no  "st  "ere 
the  free  Inhalation  of  ether  will  for  a  time  at  enuate  the  distress. 
The  effects  are  generally  fugitive;  nevertheless,  the  an*^  f"'^ 
mav  be  "the  last  straw  that  breaks  the  camels  back,  and 
Se Vroxysm  may  yield  to  a  few  whif!s  of  ether  or  chloro  or^ 

Of  the  two.  chloroform  is  the  most  prompt  and  thorough 
in  its  action,  producing  less  nausea  and  vomiting  afterwards, 
but  ether  is  generally  preferred,  being  safer. 

Latelyfdeep.  parenchymatous  *")««="°"«/PXru  Bar- 
form  (ao  to  30  drops),  have  been  rrcommended  (Roberts  Bar 
thoTow,  Ernest  Besnler,  Dujardin-Beaumetz,  etc.).  «n  sciatica 
The  needle  should  be  plunged  deept,  into  the  muscular  inter. 

has  bein  klso  used  locally  as  a  liniment,  over  painful  regions, 
and  wUMood  results^  ^^  ^^^^^^^.^  ^^^^^  ^^^  ^^  ^^^^ 

tloned  If  sprayed  over  a  painful  region-a  common  hand 
atomizer,  such  as  is  made  by  Codman  &  Shurtlefl,  Boston, 
w£  th;ows  a  continuous  spray,  being  usei  ^o' the  purpose- 
an  intense  refrigeration  is  produced^  which  benumbs  the  nerves 
and  for  a  time  allays  the  pain.  These  P"*^'"'""*'"^  *"  °/ 
considerable  use  in  dermalgia.  in  occipital,  temporal,  and  inter, 
costal  neuralgia,  and  I  have  known  them  to  be  used  with  bene- 
fit in  sciatica, 

NITRITE    OF   AMYL. 

Nitrite  of  amyl  has  been  used  with  some  success  by  in- 
halation (three  or  four  drops  on  a  handkerchief  or  the  palm  ot 
The  hand  in  facial  and  intercostal  neuralgias  and  '«  hem.crania^ 
Most  authorities,  however,  place  very  little  reliance  on  it  From 
the  vaso-motor  paralysis  and  the  congestions  whjch  it  occa- 
sions, it  is  likely  to  do  more  harm  than  good.  Vanlair  thinkt 
It  of  remarkable  efficiency  in  sympathetic  head.  ;nes. 


.w>iji!miiiiiMi<iBigUiH'W5  ■" 


W^'.iWttg'<!l.'>Ml.t4;yJW/t^?^j"J^J!^.Jt^.W:f^^^''.V4ll.'.51".\'"'  * 


■■'"■'lyJQBfCWIK'-  ■ 


r  ser- 
There 
ent  is 
irvico- 
poder- 
point, 
squent 
Here 
stress, 
sthetic 
."  and 
ofortn, 
trough 
wards, 

chloro- 
is  Bar- 
:iattca. 
•  inter- 
ukedly 
nfnl  of 
irachial 
rofotm 
egions, 

e  men- 
n  hand 
Boston, 
rpose — 
nerves 
are  of 
d  inter- 
h  bene- 


is  by  in- 
palm  of 
licrania. 
;,  From 
it  occa- 
ir  thinks 


—    "7 


('III.OKAI., 


Chloral  has  hut  feeble  analgesic  properties.  It  is  never 
given  in  neuralgias  of  any  kind  except  as  an  adjuvant  to  mor- 
phine, to  calm  reflex  excitability  and  produce  slt-ep.  The 
dose  is  from  lo  to  30  grains. 

For  externa!  use  a  liniment  is  prepared  called  the  r«w- 
phor-chiorai  Unimtnt,  by  rubbing  gum  camphor  with  hydrate  of 
chloral.  An  oily  liquid  is  the  product,  which,  when  rubbed 
over  ihe  seat  of  pain  in  pleurodynia,  cervico-bracbial  neural- 
gia, lumbago,  etc.,  causes  first  some  smarting  and  redness,  then 
considerable  local  anaesthesia. 

CROTON-CHLORAL. 

This  substance  seems  to  possess  analgesic  properties 
superior  to  thore  of  chloral.  Per  contra,  it  is  not  so  good  a 
hypnotic.  It  has  given  good  results  in  facial  neuralgia  and 
in  migraine.  The  dose  is  live  grains;  Seguin  counsels  to 
give  15  grain?  every  hour,  for  four  doses,  in  migraine. 

Not  much  can  be  expected  of  this  remedy,  although  Dr. 
B.  W.  Richardson  {Braithwaile's  Rft.,  Part  83.  p.  228)  spealcs 
highly  of  its  employment.  He  says;  "  Looking  upon  neural- 
gia as  a  form  of  vascular  spasm  in  tracts  of  nerves  (?),  we  have 
a  clear  idea  of  the  reason  why  antispasmodics  are  so  useful  in 
some  forms  of  this  disease.  »         #         •         »         jhe 

alcohol  in  port  wine  has  for  this  reason  obtained  its  reputation 
for  the  relief  of  tic.  In  croton-chloral  combined  with  quinine 
we  have  an  instant  remedy  more  effective  than  alcohol.  *  • 
The  formula  is: 

Croton-chloral,  gr.  ii.         ^ 

guinine,  gr.  ii. 
lycerln,  as  much  as  suffices  to  make  a  pill. 

The  pill  to  be  taken  when  the  attack  threatens,  and  to  be  re- 
peated every  two  hours  till  relief  is  obtained." 

BROMIDE  OF   POTASSIUM. 

Peter  relates  a  case  of  cure  by  bromide  of  potassium  of 
an  epileptiform  neuralgia  of  the  face;  the  patient,  aged  63 
years,  had  more  than  200  crises  in  the  twenty-four  hours, 
and  could  only  get  relief  from  bis  pain  by  taking  half-drachm 
doses  of  bromide  three  times  a  day.* 


*  Build*  Thtrap.y  Oct.,  i8;6,  p.  337  doited  by  Vanlair). 


■--gg'-^'^'i'tf'i'^iVW^gg   ^i- 


k: 


pi 


!    ' 


—    IlH   — 

Anstie*  would  limit  its  use  mainly  to  a  class  of  neuralglcii. 
esperiluv  women,  in  whom  a  certain  restless  hyperactivity  o 
mTnd  and  perhaps  o(  body  also,  seems  to  be  the  expression  of 
Na"u  e*s  unconscious  resentment  of  the  neglect  of  sej*""  '""^^ 
tions.  Bromide  of  potassium,  on  the  other  hand,  is  injurious 
in  young  men  exhausted  by  masturbation. 

oil.  OK   rKPPRRMINl— MKNTHOL. 

Menthol  is  a  solid  crystallizablc  substance  deposited  from 
thf.  oil  of  oepperminl.  It  is  also  found  in  commerce  under 
tc  name  of  Tapa^.ese  oil  of  peppermint.  Oil  of  .-PP""?'"' 
and  menthol  arc  supposed  to  have  an.  dyne  properties  when 
aJpliTd  externally,  but  probably  their  iherapeujlc  action  de 
pends  on  their  rapid  and  complete  evaporation  Oil  of  peppe- 
mint  has  been  much  used  as  a  liniment  in  s  jperficial  neurai- 
Jas.  AsoTuUrof  menthol  In  alcohol  «nd  menthol  cones, 
have  also  been  found  of  some  use,  especially  it*  migraine. 

COCAINE. 

Cocaine  is  an  alkaloid  obtained  from  the  '"ves  of  ery- 

throxylon  coca.  The  marked  local  »,"«"''"'' jfoflatrlln 
have  been  obtained  from  this  agent,  aiid  which  have  o' '»"««: 
dered  It  so  Indispensable  In  ophthalmic  surgery,  and  i"  minor 
surgical  operations,  have  led  to  its  employment  as  a  topical 
application  In  neuralgias.  Unfortunately  Its  action  Is  too  su- 
J«ftclal  and  too  translto-y.  A  strong  «o>""on  rubb'd  over 
oainful  nerves,  or  applied  v  tampons  and  compresses— in  tic 
douloureux,  in  migraine,  In  Intercostal  and  other  peripheral 
neuralgias— gives  but  momentary  %  .eviatlon. 

Hypodirmlc  injections,  each  lni«tion^<^ons.stng  of  a 
syrlngful  of  the  two  per  cent,  solution  o.  the  hydrochiorate  of 
cocaine-have  been  used  In  neuralgia  with  «ome  benefit  In 
one  Instance  of  severe  cervlco  brachial  neuralgia.  whe«  I 
frequently  resorted  to  these  injections,  the  anagelsic  eff«t  was 
speedy,  and  lasted  several  hours.  At  the  same  time,  some  ob^ 
servers  have  recorded  among  the  unfavorable  syrnptoms 
attending  the  subcutaneous  use  of  cocaine,  nausea,  and  even 
alarming  syncope. f 


•  Anstie,  "  On  Neuralgia."  p.  W;     ,         .       n- j    „  .„ 
+  Duj«rdin-BeaumetxrNew  Medications,  Am.  Ed,  p.  300- 


■!ill"<»Ul  llJ>lW.*IA'-',Jjlt'MPirW 


"■)-'^r'.H'wv."ff-g^g^' 


y  of 
n  of 
unc- 
ioui 


Irom 
nder 
miat 
vhen 
I  de- 
pper- 
lural- 
snes, 


;  ery- 

which 
s  ren- 
Tiinor 
apical 

30  fcU- 

over 
-in  tic 
pheral 

[  of  a 
ate  of 
t.  In 
lere  I 
ct  was 
ne  ob- 
ptoms 
I  even 


—    I  19   — 

From  my  own  limiied  rxpericnce  I  should  say  ihat  if  the 
patient  be  Itepi  in  a  recumbent  position,  there  is  little  danger 
of  syncope,  and  that  the  occasional  use  of  cocaine  siibcu- 
tantously  in  neuralKla,  as  a  substitute  for  morphine,  is  advan 
t.i|{eous. 

111.— Nrurosthknic  or   Ai.tkrativk  Mkdicaments. 

The  medicines  above  enumerated  do  Rood  chietiy  by  an 
action  directed  to  ihe  element  pain,  and  their  effect  is  more  or 
less  transient.  Moreover,  some  of  them,  as  opium,  are  objec 
tionable  in  Ihat  the  organism  is  liljelytobe  in  a  worse  condition 
after  their  use  than  before,  lie  who  is  obliged  constantly  to 
resort  to  morphine  injections  is  almost  certain  to  become  a 
morphiomanlac.  Nor  can  it  be  said  that  the  constant  use  of 
belladonna,  cannabis,  or  any  other  narcotic  is  unattended  with 
injury  to  the  organism. 

Perhaps  the  same  objection  is  not  (at  least  to  the  same 
extent)  applicable  to  a  class  of  medicines  which  1  may  call  neu- 
rosthenic  or  alterative  medicaments,  which  are  designed  10 
strengthen  the  nerve  element.  Of  this  class  I  shall  notice  only 
the  principal  :  Arsenic,  quinine,  salicin.  iron,  phosphorus, 
chloride  of  ammonium,  strychnia,  and  cod-liver  oil. 

ARSENIC. 

Perhaps  no  remedy  is  more  prized  at  the  present  day  in 
anamic  neuralgias  than  arsenic.  This  medicine,  says  Anslie 
"from  its  singularly  happy  combination  of  powers  as  a  blood 
tonic,  a  special  stimulant  of  the  nervous  system,  and  withal,  as 
a  special  opposer  of  the  periodic  tendei  cy.  must  be  regarded  as 
one  of  the  most  powerful  weapons  in  the  physician  s  hands, 
and  although  it  seems  to  act  best  in  the  neuralgias  of  the  vagus 
and  the  fifth,  there  is  a  possibility  of  iis  proving  the  most  effect- 
ive remedy  in  almost  any  given  case  which  may  come  beiore 
us  "  Anstie  has  seen  especially  good  results  from  arsenic  in 
the  paroxysms  of  angina  pectoris;  from  his  description  it  would 
appear  that  he  refers  to  those  purely  neurotic  forms  of  cardiac 
pain  called  by  Huchard  false  angina pectons. 

Cohen*  has  administered  arsenic  with  success  to  persons 
affected  with  all  kinds  of  cerebrospinal  neuralgias,  fac.al, 
sciatic,  intercostal,  etc.  Sciatica  has  been  the  most  refractory  to 
this  remedy.     Leared  has  found  it  very  efficacious  in  gastralgia. 


•  hurnal de Miduini  de  BruxtlUs,  1865.    (CiWd  by  Vanlair). 


■-■  .5*'W!'?*.iW4!U;?" 


120    — 

!)()«•  and  mode  of  administration.  — I,  Fowler's  solution, 
three  dropB,  KCi'dimllv  inrrea^ed  to  eiifhl  or  ten,  .ifter  each 
meal.  3,  Arsenlr.il  pills  ,'«  to  ..',,  grain;  one  pill  thrre  time*  a 
day.  The  granules  of  Diomorldes  an<l  the  Asiam  pills  are 
anrlent  proparation*.  Fowler's  solution  ran  genf  r.illy  he  toU 
erated  if  any  ar«enif<»l  preparation  can  he  taken,  but  in  some 
patients  arsenic  in  every  form  is  conira-indl'.ttle-l,  twing  lo 
gaitro  intestinal  irritability. 

l.>|l|NI.NI. 

Quinine  has  a  great  reputation  in  the  treatment  of  neural- 
gia, a  reputation  which  is  largely  due  to  Its  su'  i-css  In  those 
forms  of  neuralgia  which  are  of  malarial  origin.  There  is  no 
doubt  as  to  its  utility  in  these  latter  neuralgias.  The  dtisc  should 
be  large,  from  to  to  15  grains  to  an  adult;  this  may  be  given  to 
best  advantage  a  few  hours  before  the  paroxysm;  Stille  says 
■ix  to  eight  hours. 

Numerous  examples  of  the  efficacy  of  quinine  In  neural- 
gia of  the  ulna,  sciatic,  crural,  and  other  nerves  have  been 
given  by  Dr.  Hanfield  Jones.*  A  case  of  femoro  popliteal  neu- 
ralgia was  cured  by  Dupr^  with  auinine  after  other  remedies 
had  failed,  and  Brodle  successfully  treated  neuralgia  of  the 
inferior  dorsal  nerves  by  the  same  remedy.*  Anstie  ascribes 
to  it  a  special  value  in  the  treatment  of  ophthalmic  neuralgia; 
Vanlair  finds  it  indicated  particularly  in  neuralgias  of  the  face 
and  neck,  and  regards  the  existence  of  marked  periodicity  in  the 
paroxysms  as  a  leading  indication  for  quinine. 

It  is  better  to  give  quinine  in  substance  in  a  little  water 
and  made  soluble  by  a  drop  of  a  mineral  acid,  than  in  pill  form. 
If  administered  in  an  infusion  of  coffee,  its  bitterness  is  partly 
disguised.  Graves  reccommends  the  addition  of  a  few  drops  of 
chloroform  to  the  mixture,  which  is  thus  rendered  more  pala- 
table. 

SALICIN. 

Salicin  is  a  glycoside  obtained  from  willow  bark.  It  has 
been  used  in  neuralgia  chiefly  on  the  recommendation  of  Dr. 
Maclagan  "The  cases,"  he  says,  "in  which  I  have  found 
salicin  to  be  of  most  service  are  those  in  which  the  pain  comes 
on  in  periodic  exacerbations,  and  in  which  quinine  either  fails 


•  Lancet,  June,  11)65,  (quoted  by  Stiiic.) 

t  Stilli,  Tktraptutks  and  Afatfria  ytidica. 


ii 


—   Ill 


ition, 
earh 
irn  a 
s  ure 
r  tol. 
some 
ig  lo 


!urttl- 
those 
is  no 
dould 
■en  to 
!  says 

•ural- 
been 
Ineu- 
ledies 
if  the 
:ribeB 
atgia; 
:  face 
in  the 

water 
form. 
>Hrtly 
spsof 
pala- 


t  has 
f  Dr. 
found 
;ome8 
r  fails 


tn  dn  gnod,  or  Is  forsnme  reason  Inadmlinlhlp."  Mr  has  ((iven 
it  chiefly  In  farial  neiiralxiii  The  dos"  must  br  lurKe;  twenty 
grains  every  three  hours  till  eighty  grains  are  t.ikcn,  or  till  the 
pain  subsides.    {PriutiiinHfr,  Nov.,  1877   p.  3ai.) 

IRON. 

It  is  not  surprising  that  iron,  whirh  on  uples  surh 
a  large  place  in  the  therapeutics  <>f  uiiicmiu  and  debility,  should 
be  regarded  as  a  remedy  of  prime  importance  in  neuralgia,  a 
disease  of  anfcmia  and  debility;  and,  doubtless,  as  nn  adjuvant 
to  good  food,  exercise  in  the  opf>n  air,  and  other  fortifying 
measures,  iron  may  render  important  service  in  the  treatment 
of  neuralgia. 

Anstie  speaks  highly  of  the  tincture  of  sesquichloride  of 
iron  in  the  anremir  neuralgias.  He  thinks  that  besides  its 
effects  on  the  blood,  it  has  a  marked  and  direct  influence  on 
the  nerve  centres  which  is  different  (rom  anything  which  one 
observes  in  the  actiori  of  any  other  preparation  of  iron.*  The 
effect  which  it  produces  in  the  an<emic  neuralgias,  more  es- 
pecially of  young  women,  is  something  quite  peculiar.  He 
recommends  the  combination  with  strychnine,  ten  minims 
of  the  tincture  of  the  chloride  with  one  fortieth  of  a  grain  of 
strychnine,  and  alludes  to  a  severe  case  of  frontal  neuralgia 
that  was  markedly  benefitted  by  this  combination.  (The  dose 
is  an  exceedingly  unpleasant  one  to  take,  and  the  tincture  of 
iron  doubtless  has  a  deleterious  action  on  the  teeth). 

Another  favorite  iron  preparation  is  the  saccharated  car- 
bonate, of  which  the  dose  is  a  scruple  three  times  a  day. 

Hutchinson  affirms  that  he  has  cured  several  cases  of 
temporo-facial  neuralgia  by  the  subcarbor.ate  in  large  doses. 
A  teaspoonful  may  be  given  of  this  rr-d  iron  powder  stirred 
into  a  little  water,  three  times  a  day,  The  phosphate  and 
pyrophosphate  (especially  the  latter)  are  eligible  preparations. 
In  chlorotic  patients  with  delicate  stomachs  the  ammonio-ciu 
rate  will  sometimes  suit  better  than  any  other  form  of  iron. 

Among  the  useful  non-official  preparations  is  the  thxif  of 
phosphate  of  itoH,  quinia  and  strychnia;  dose,  a  teaspoonful 
three  times  a  day;  the  elixir  of  lac  top  hasp  hale  of  iron;  the  fol- 
lowing  formula  of  Dr.  W.  A,  Hammond  is  a  powerful  tonic 
combination: 


*  A Httit  OH  Neuralgia,  Am.  Ed.,  p.  aig. 


—     122    

IJ    Pyrophosphate  of  iron.  J  i, 

Quinine  sulph.,  3bs, 

Strvchnine,  (jr.  j, 

Acid  phosphoric  dilute. 

Syrup  of  ginger,  iiii  i  ij. 
M.     Dose,  a  teaspoonful  three  tim^s  a  day. 

CHLORIDE  OF  AMMONIUM. 

Dr.  Eben  Watson  has  represented  this  drug  to  be  an  effic- 
ient remedy  for  neuralgia  of  the  fifth  pair  of  nerves,  and  he 
refers  to  two  cases  in  which  the  pain  ceased  within  a  few  min- 
utes after  it  had  been  given.*  Anstie  also  speaks  favorably  of 
its  use  in  migraine. 

The  dose  is  20  grains  dissolved  in  a  large  quantity  of 
water.  Muriate  of  ammonia  is  a  very  disagreeable  medicine 
to  take,  The  addition  of  a  little  licorice  renders  it  somewhat 
more  palatable. 

STRYCHNINE. 

If  nux  vomica  or  strychnia  has  any  efficacy  in  neuralgias, 
it  is  by  improving  the  circulation  of  the  blood  and  the  tone  and 
nutrition  of  the  nerves  on  which  it  acts.  It  is  principally  in  the 
facial  neuralgias  and  in  gastralgia  that  it  proves  beneficial. 
Anstie  speaks  of  the  utility  of  strychnia  in  "cardiac  neuralgia," 
though  he  gives  the  precedence  to  arsenic. 

The  dose  of  strychnia  would  be  from  ^5  to  -^  grain,  ad- 
ministered in  pill  form.  The  liquor  strychnia  may  be  given  in 
doses  of  from  5  to  10  drops. 

Of  nux  vomica,  one  grain  of  the  powder,  one-fourth  grain 
of  the  extract,  or  five  drops  of  the  tincture  may  be  given  for  a 
dose. 

PHOSPHORUS. 

The  use  of  this  drug  is  altogether  empirical.  It  has  been 
given  in  the  pill  form,  each  pill  containing  f^^  grain.  The 
phosphorated  oil  is  not  a  very  eligible  preparation, though  it  may 
be  administered  in  capsules,  each  capsule  representing  one-six- 
tieth of  a  grain,  to  be  taken  after  meals.  Phosphide  of  zinc  is 
an  excellent  form  for  the  administration  of  phosphorus;  pills 
y^  grain ;  dose,  one  pill  after  each  meal.  Thompson  in  Eng- 
land, and  W.  A.  Hammond  in  this  country  are  the  principal 
advocates  of  the  phosphorus  treatment  of  neuralgia. 


*  StllU,  Therapeutics  and  Materia  Med.,  Vol.  II,  p.  819. 


123 


eflSc- 
id   he 

itiin- 
bly  of 

ty  of 
licine 
;what 


Igias, 
e  and 
in  the 
ficial. 
Igia." 

a,  ad- 
'en  in 


grain 
for  a 


1  been 
The 
tmay 
le-six- 
linc  is 
;  pills 
Eng- 
ncipal 


COD  LIVER  OIL. 

There  is  no  question  as  to  the  value  of  fatty  foods  in  neu- 
ralgia, although  patients  are  often  averse  to  them,  and  many 
with  delicate  stomachs  are  unable  to  tolerate  or  digest  crude 
fats  in  any  form.  The  neuralgic,  as  a  rule,  are  lean  and  ana- 
mic.  The  appetite  is  poor  and  assimilation  is  imperfect.  The 
pains  from  which  they  suffer  are  often  the  outcry  of  starved 
nerves  for  more  blood  and  better  blood.  If  we  would  do  these 
patients  good,  we  must  do  something  besides  alleviating  the 
pain  for  the  time  being.  They  must  be  built  up  by  generous 
diet  of  which  flesh  and  fats  form  a  considerable  proportion. 
As  nerve  substance  is  composed  chiefly  of  albumen  and  fat,  we 
see  the  importance  of  an  abundant  supply  of  these  materials  in 
the  food. 

But  what  can  be  done  in  cases  where  the  appetite  is  absent 
—where  the  stomach  loathes  the  kind  of  food  that  is  needed  ? 
As  far  as  possible,  all  the  resources  of  hygienic  therapeutics 
must  be  called  into  exercise;  pure  air,  out  door  exercise,  moun- 
tain climbing,  horseback  riding,  rowing,  walking,  gymnastics. 
Or  if  the  patient  be  bedridden,  massage  and  electricity  may  be 
tried,  with  feeding  according  to  the  Weir- Mitchell  method.  Such 
fats  ascan  be  asfimilated  must  be  taken:  sweet  cream,  salad 
oil,  above  all,  cod-liver  oil.  In  addition  to  the  ordinary  fare,  a 
cup  of  beef  peptonoids  between  meals,  and  in 'the  night  time. 
If  cod  liver  oil  in  its  purity  cannot  be  borne,  possibly  some  of 
the  emulsions  may  suit,  especially  that  with  malt  extract. 

"It  is  "says  Anstie  "  surprising  what  can  be  done_  in 
in  this  way  by  perseverance  and  tact.  *  *  *  *  Nothing 
is  more  singular  than  too  see  a  girl  who  was  a  peevish,  fanci- 
ful and  really  very  suffering  migraineuse  brought  to  a  state  in 
which  she  will  eat  spoonful  after  spoonful  of  Devonshire 
cieam,  and  at  the  same  time  lose  her  headaches,  lose  her 
sickness  and  develop  the  appetite  of  a  day  laborer." 

IV.     Modifiers  of  the  Nervous  System.     Analgesics— 
Antipyrin. 

Of  all  the  analgesic  medicines  which  have  ever  been  pre- 
scribed for  the  neuralgic  affections,  antipyrin  seems  to  have 
been  the  most  uniformly  successful,  as  well  as  the  most  harm- 
less. Not  even  opium  or  morphine  can  be  excepted,  for  opium 
does  not  more  speedily  relieve  pain  than  aniipyiin  in  cases 


—    124    — 

for  which  the  latter  is  adapted,  nor  are  the  effects  more  per- 
manent; besides  at  what  cost  is  the  analgesia  of  opium  some- 
times obtained. 

History. — Antipyrin  was  discovered  in  1885  by  Knorr, 
of  Eriangen,  Germany,  It  is  one  of  the  products  of  the  destruc- 
tive distillation  of  coal  tar.  Antipyrin  is  a  derivative  of  oxy- 
menthl  quinizine,  which  is  obtained  by  the  reaction  of  aceta- 
cetic  ether  on  phenylhydrazine;  if  to  this  oxymethyl  quinizine 
there  is  introduced  a  new  metbylic  group,  methylated  oxy- 
methyl quinizine  is  obtained,  to  which  Felehne  gave  the  name 
of  antipyrin.  It  is  a  grayish  white  powder,  slightly  bitter  to 
the  taste,  and  quite  soluble  in  water.  The  chemical  formula 
of  antipyrin  is  C,oH,oNgOg. 

The  manufacture  of  antipyrin  has  unfortunately  fallen 
into  the  hands  of  a  monopoly,  which  has  patented  the  name  in 
all  civilized  countries;  hence  the  price  of  this  drug  has  been 
relatively  high.  It  is  not,  however,  maintained,  that  the  pro- 
cess of  its  manufacture  is  in  any  sense  a  secret. 

Physiological  Action. — While  antipyrin  in  large  doses  is 
speedily  fatal  to  animals,  producing  convulsions  both  clonic 
and  tonic,  and  paraplegia  or  general  paralysis,  in  smaller, 
medium  doses  its  action  is  characterized  by  diminution  of  the 
sensory  perception,  and  reflex  excitability.'* 

G.  See,  and  Chouppe  have  demonstrated  that  antipyrin 
lessens  the  excitO' motor  properties  of  the  cord,  and  that  it  is 
also  a  sedative  to  the  cerebrum.  This  physiological  action 
gives  hints  as  to  the  modus  operandi  of  its  therapeutic  action  in 
cases  characterized  by  sensory  hyper-excitability. 

We  are  not  here  concerned  with  antipyrin  in  its  relation 
to  fever,  and  those  marked  anti- thermic  effects  which  make  it 
perhaps  our  best  antipyretic. 

Therapeutic  Employ. — After  antipyrin  had  been  for  more 
than  a  year  employed  in  fevers,  it  was  found  to  be  of  prime 
utility  in  combating  the  element  pain.  Nor  is  it  strange  that 
a  remedy  which  lowers  fever-heat  by  depressing  the  activity  of 
the  heat  centres,  should  do  good  in  other  conditions  dependent 
on  abnormal  nervous  activity.  It  was  found  to  be  of  benefit 
in  acute  rheumatism,  by  alleviating  the  pains  in  the  joints. 
Professor  Germain  See  was  one  of  the  first  to  point  out  the 
analgesic  properties  of  antipyrin  in  all  other  affections  where 
pain  is  a  predominant  symptom.      He  reported  a  first  series  of 


*  Dujardin-Beaumetz,  DictionHaire  dt  ThtrapeutiQut 


per- 
itne- 

orr, 
ruc- 
5xy- 
eta- 
zine 
3xy- 
ame 
r  to 
dula 

Hen 
e  in 
)een 
pro- 

s  is 

anic 

Her, 

the 

yrin 
it  is 
tion 
1  in 

tion 

:e  it 

lore 
ime 
that 
f  of 
lent 
lefit 
nts. 
the 
lere 
s  of 


—   125  — 

observations,  fourteen  in  number,  relative  to  pains  of  the 
head;  of  these,  four  were  cases  of  facial  neuralgia;  six  were 
obstinate  cases  of  migraine;  four  were  the  headaches  of  grow- 
ing children.  Iri  all,  antipyrin  caused  the  pains  rapidly  to 
cease. 

A  second  series  of  observations  pertained  to  eighteen 
cases  of  neuralgia  or  neuritis,  and  of  muscular  pains;  to  five 
cases  of  sciatica;  to  several  cases  of  painful  zona,  of  lumbago, 
etc.     In  all  these,  antipyrin  proved  efficacious. 

Wolfif  has  found  antipyrin  promptly  beneficial  in  mus- 
cular rheumatism  and  pleurodynia;  Ungar  speaks  favorably  of 
its  effects  in  hemicrania,  and  in  those  headaches  which  accom- 
pany ophthalmias;  while  Lepine  and  Germain  See  have  found 
severe  cases  of  the  douUurs  fulgurantes  of  tabes  dorsalis 
amenable  to  the  same  remedy  Professor  See  has  also  had 
good  results  from  antipyrin  in  angina  pectoris. 

Otalgia  (earache)  has  been  treated  with  success  by  anti- 
pyrlne  (Gomprez),  and  lumbago,  whatever  be  its  origin,  ac- 
cording tc  Germain  Sfee,  gets  well  immediately  after  two  sub- 
cutaneous injections  of  five  grains  of  antipyrin,  with  forty-five 
grains  taken  internally. 

In  visceral  pains  (hepatic,  nephritic,  gastro-intestinal 
colic,  uterine  colic).  Germain  S6e  has  never  known  antipy- 
rin to  fail.  His  treatment  is  a  hypodermic  injection  of  fifteen 
grains,  aided  by  fifteen  grain  doses  by  mouth  four  times  a  day 
for  eight  days.  In  painful  dyspepsias,  he  associates  antipyrin 
with  bicarbonate  of  soda,  eight  grains  of  each,  three  times  a 
day  at  meal  times.  In  painful  menstruation  he  gives  a  lave- 
ment containing  fifteen  grains  of  antipyrin. 

Mode  of  Administration  and  Z>w«.— Antipyrin,  being 
soluble,  is  readily  administered  in  water,  or  in  alcohol  and 
water.  Simple  elixir  is  a  good  excipient.  The  dose  is  from 
ten  to  twenty  grains.  Ten  or  fifteen  grain?  may  be  given  every 
hour  or  two  till  six  doses  have  been  given.  Antipyrin  may  be 
safely  administered  in  hypodermic  injections.  Seven  or  eight 
grains  are  dissolved  in  one  or  two  cubic  centimitres  of  water, 
and  the  whole  injected  under  the  skin.  A  little  smarting  fol- 
lows the  injection,  which  soon  passes  off. 

Antipyrin  sometimes  causes  a  scarlatiniform  rash, 
which,  however,  is  never  serious.  Now  and  then  a  little 
nausea  or  vertigo  attends  its  medicinal  use,  but  it  never  causes 
the  depression  and  cyanosis  which  frequently  attend  the  use  of 
acetanilid. 


126 


TONGA. 


Tonga  is  a  new  remedy  for  neuralgia,  introduced  to  the 
profession  by  Sidney  Ringer  and  William  Murrell  of  London, 
in  1880,  and  obtained  from  the  Fiji  Islands.  It  has  long  been 
used  by  the  South  Sea  Islanders  for  all  cases  of  neuralgia.  It 
is  employed  in  the  form  of  an  alcoholic  extract,  in  the  dose  of 
a  teaspoonful  every  few  hours.  Its  effects  seem  to  be  very  sim- 
ilar to  those  of  guarana.  A  good  preparation  of  tonga  is  made 
by  Parke,  Davis  &  Co. 

GUAR  ANA— CAFFEINE. 

Guarana,  and  its  alkaloid,  caffeine,  are  somewhat  famous 
anti-neuralgic  remedies.  Guarana  was  first  brought  into  notice 
about  twenty  years  ago.  It  is  the  product  of  a  Brazilian  plant, 
the  Paullinia  sofbilis.  Caffeine  exists  in  guarana  in  the  propor- 
tion of  about  s  ptr  cent.  The  discovery  of  caffeine  in  four 
plants  belonging  to  separate  natural  families,  namely:  the 
coffee  and  tea  plants,  the  Paraguay  tea,  and  the  Paullinia,  is 
an  interesting  result  of  recent  chemical  investigations.* 

Physiological  Action. — Guarana  and  its  alkaloid  act  much 
like  tea,  coffee,  and  cocoa,  causing  at  first  excitation,  then 
diminution  of  the  functions  of  the  cerebrum  and  spinal  cord. 
Beaumetz  sums  up  the  principal  effects  as  follows:!  '-  cerebral 
excitation;  a,  complete  paralysis  of  the  sensibility;  3,  tetanic 
sp  .ms  and  convulsions;  n,  death.  "  These  poisons,  then, 
seem  to  paralyze  the  posterior  columns  of  the  spinal  cord,  and 
the  entire  system  of  sensory  peripheral  nerves,  having  no 
actior  on  the  anterior  columns  and  motor  nerves." 

These  are  the  principal  points  of  interest  in  connection 
with  the  anti-neuralgic  uses  of  guarana  and  caffeine.  It  is  evi- 
dent that  the  analgesic  action ,  which  is  the  one  sought  for,  can- 
not be  dependent  on  the  paralyzing  action  of  the  drug  on  the 
sensory  nerves  and  centres,  which  follows  large  doses. 

Therapeutic  Uses. — It  is  especially  in  migraine  that  guar- 
ana or  its  alkaloid  have  proved  beneficial.  Nevertheless,  facial 
neuralgia  has  proved  amenable  to  its  use,  and  the  supra-orbital 
and  infra-orbital  headaches. t  Common  sick  headache,  so  gen- 
erally referred  to  gastro  hepatic  derangement,  is  often  marked- 


*  Wood  &  Bache,  U.  S.  Dispensatory. 

t  Dujardin-Beaumetz,  Dictionaire  de  Therapeutique. 

i  Vanlair,  Loc.  Cit. 


SafcaJt^E-l^jseisSB^s-i! 


o  the 
ndon, 
been 
a.  It 
ose  of 
J  siiti- 
made 


imous 
lotice 
plant, 
ropor- 
four 
:  the 
lia,  is 

much 
,  then 
cord, 
rebral 
etanic 
then, 
1.  and 
ng  no 

ection 
is  evi- 
r,  can- 
}n  the 

guar- 
facial 
>rbital 
3  gen- 
iirked- 


—   127   — 

ly  relieved  by  guarana,  and  I  have  witnessed  one  case  of  cer- 
vico-brachial  neuralgia,  which  for  more  than  three  years  was 
kept  in  abeyance  by  this  drug.* 

Doses. — The  dose  of  guarana  is  fifteen  to  thirty  grains; 
that  of  caffeine,  three  to  six  grains.  The  former  may  be  taken 
well  stirred  in  a  little  warm  water,  as  a  wineglassful.  The 
caiTeine,  which  is  generally  given  in  the  form  of  a  citrate  (the 
citrate  is.  however,  merely  a  mechanical  combination  of  caf- 
fein  and  citric  acid,  and  not  a  true  salt)  may  be  taken  in  a 
spoonful  of  syrup,  simple  elixir,  or  w.'ter.  The  dose  may  be 
repeated  in  an  hour  or  two  if  no  result  is  derived  from  the  first 
dose. 

"I  know,"  says  Dujardin-Beaumetz,  "a  physician  who 
infallibly  cuts  short  his  attacks  of  migraine  by  the  use  of  one 
or  two  grammes  of  guarana."  This  has  been  a  frequent  ex- 
perience. I  personally  know  many  (mostly  delicate  females) 
who  were  formally  martyrs  to  nervuus  headaches,  and  who 
have  for  years  been  made  comfortable  by  an  occasional  scruple 
dose  of  guarana,  taken  in  time  to  ward  off  an  impending  par- 
oxysm. 

Dujardin-Beaumetz  {Dictionnairi  de  Thtraftutique,  art. 
Guarana)  gives  the  following  directions  for  the  administration 
of  guarana:  "  If  the  attacks  of  migraine  are  frequent  (several 
a  month),  take  every  morning  two  grammes  of  guarana,  half 
an  hour  before  breakfast, 

"  At  the  onset  of  an  attack,  or,  better  still,  as  soon  as  the 
precursory  symptoms  show  themselves,  take  seven  and  one- 
half  grains  in  a  little  sweetened  water;  wait  a  quarter  of  an 
hour,  if  the  migraine  is  not  gone,  repeat  the  dose." 

Formulae: 

B     Fluid  ext.  ^arana,  ^j. 
Dose,  a  teaspoonful  p.  r,  n. 

The  combination  of  caffeine  and  guarana  is  sometimes 
more  efficient  than  either  the  one  or  the  other  alone: 

B    Guarana  in  fine  powder,  9  j. 
Citrate  caffeine,  gr,  iij. 


♦  Afed.  Record,  1816,  page  743:      "Dr.  H.  C.  Perkins,  the  attending 

ghysician,  had  obtained  a  quantity  of  Paulhnia  from  Brazil.    *    *    *  Some 
rilliant  cures  were  wrought,  and  every  form  of  neuralgia  seemed  to  be 

controlled  by  the  Paullinia  powders.    In  the  case  of  Miss  R ,  the  good 

effects  were  especially  marKed.    *    *    *    Her  general  health  improved. 
For  four  yeais  there  was  almost  complete  immunity  from  the  pain." 


^^  I 


M 


—  128  — 

Make  one  powder.  To  take  in  a  little  water  when  pre- 
cursory symptoms  first  appear.  This  dose  will  sometimes 
interrupt  an  attack  that  is  in  progress. 

Anti-neuraloic  Powder.— (Dujardin-Beaumetz.) 

Q    Caffein,  o  gt.  to  10  ceatifrr. 

White  sugar,  o  gr.  to  50  centifrr. 
M.  One  powder,  p.  r.  n. 

Bamberger's  Anti-neuralgic  Powder, — 

B    Sulphate  of  quinine,  o  Rr.  to  50  centiKr. 

Citrate  of  caftein,  o  gr.  30  centigr. 

White  sugar,  5  grammes. 
M.  Divide  in  chart.  No.  vi.    Sig.— Take  four  a  day. 

Syrup  of  Citrate  of  Caffeine. — (Hannon.) 

Q    Cit.  caffeine,  4  grammes. 

Simple  syrup,  130  grammes. 
M.  Sig.— A  teaspoonful  as  often  as  indicated. 

ACETANILII>-(ANTIFEBRIN), 

The  introduction  of  acetanilid  into  therapeutics  is  due  to 
Cohn  and  Hepp,  in  1886,  who  first  made  known  its  antithermic 
properties,  and  called  it  antifebrin.  Acetanilid  is  obtained 
b'  the  action  of  glacial  acetic  acid  on  anilin.  It  is  a  substance 
of  a  beautiful  pearly  white  color,  of  slightly  pungent,  not  dis- 
agreeable, taste.  Very  crystallizable.  It  is  but  very  slightly 
soluble  in  water.     Its  chemical  formula  is  CgH,NO. 

Physiological  Effects. — There  is  nothing  in  the  physiologi- 
cal effects  of  this  drug  especially  suggestive  of  the  analgesic 
action  which  medicinal  doses  exercise  in  many  forms  of  pain. 
It  is  true  that  large  toxic  doses  are  attended  with  abolition  of 
sensibility,  but  it  has  not  been  shown  that  moderate  doses  are 
anasthetic. 

Therapeutic  Action. — Analgesic  Effects. — Dr.  Demieville, 
of  Lausanne,  was  one  of  t)ie  first  to  call  attention  to  acetanil- 
id as  a  nervous  medicament.*  He  administered  it  with  bene- 
fit in  sciatica,  lumbago,  neuralgia,  in  headaches  of  various 
kinds,  in  pains  of  obscure  origin,  in  dysmenorrhoea,  and  in  the 
lightning  pains  ol  tabes. 


•  Rtvut  Mtdical*  de  la  Suiut  Remaidt,  June  15th,  1887. 


issii- 


129   — 

Since  thecominunication  of  Dr.  Demieville,  multiludes  ot 
communications  have  appeared  in  the  medical  journals  of 
Europe  and  this  country  on  the  suoject.  The  general  verdict 
may  be  slated  as  favorable  to  the  use  of  aceianilid  as  an  anal- 
gesic  withn  a  limtied  range.  It  is  especially  in  hemicrania 
that  It  seems  to  do  good.  Some  practitioners  even  seem  to 
think  it  equal  to  antipyrin  as  an  analgesic.  The  dose  is  about 
one  half  that  of  antipyrin,  «.  e.,  ten  grains,  to  be  repeated 
three  or  four  times  a  day.  As  acetanilid  sometimes  causes 
alarming  cyanosis,  even  in  medicinal  doses,  many  practitioners 
are  shy  of  it.  A  safe  way  of  administration  would  be  to  give 
five  grains  every  two  hours  till  four  or  five  doses  arc  given. 
The  dose  may  be  given  in  capsules,  stirred  in  water,  or  in 
simple  •■yrup,  or  elixir  simplex. 

PHENACETIN. 

Discovered  in  1887  by  Kast  and  Huisberg,  the  phenacetins 
are  three  m  number:  Orthophenacetin.  metaphenacetin  a.nd  par- 
aphenacetin.    The  general  formula  is  as  follows:  C,  oH,  aNfo,. 

Orthophenacetin  and  paraphenacetin  are  medicinal. 

Phenacetin,  like  aniifebrine  and  antipyrine,  is  both  anti- 
pyretic and  analgesic;  especially  the  latter. 

As  an  analgesic,  it  has  given  good  results  in  nervous 
headaches,  m  graine,  neuralgia  of  the  trigeminus,  sciatica,  and 
the  lightning  pains  of  locomotor  ataxia.  A  dose  of  ten  grains 
ordinarily  suffices  to  allay  pain;  if  this  is  not  sufficient,  an- 
other dose  of  five  or  ten  grains  may  be  with  safety  adminis- 
tered.    Its  hypnotic  properties  are  also  considerable. 

Experiments  made  by  Dujardin-Beaumetz  in  Cochin 
Hospital  the  past  year  have  shown  that  the  phenacetins  pos- 
sess  great  medicinal  value,  are  but  little  toxic,  and  have  all 
the  properties  of  antipyrin,  while  being  superior  to  the  latter 
He  administers  it  in  the  dose  of  7^^  grains  morning  and  even- 
ing. It  being  a  matter  of  indifference  whether  ortho-  or  para- 
phenacetin be  chosen. 

Phenacetin  is  but  slightly  soluble;  may  be  given  in  cap- 
sules or  tablets,  each  containing  seven  grains.  There  need  be 
no  fear  of  any  toxic  action;  Beaumetz  has  administered  to  ani- 
mals as  much  as  three  grammes  per  kilogramme  of  the  weight 
of  the  animal  without  causing  death.  Enormous  doses, 
amounting  in  all  to  nearly  two  ounces,  were  given  in  the 
course  of  a  little  more  than  a  fortnight  to  a  patient  suffering 
Irom  tetanus,  and  recovery  was  attributed  to  the  free  use  of 

9  MM 


■.i  s' 

5  : 


i-  I 


i  » 

>  i, 


—    130   — 

the  medicament.  There  is  another  advantage  which  this 
medl:ament  possesses  ovei  antipyrin  and  acetanilid,  In  being 
perfectly  tolerated  by  the  stomach.  Its  price  is  less  than  that 
of  antipyrin,  at  the  same  time,  it  is  more  powerful  in  the  same 
dose;  in  fact,  one  gramme  of  phenacetin  produces  an  effect 
fully  equal  to  that  of  two  grammes  of  antipyrin. 

Prof.  Lepine  has  now  employed  phenacetin  for  several 
months  as  a  "  nervine  medicament,"  with  satisfacto-y  results, 
and  prefers  it  to  antipyrin  and  acetanilid.  Gaifife  has  used  it 
with  advantag''  in  the  vomiting  of  phthisis,  also  in  nervous 
polyuria.  It  has  thus  far  had  no  eflfect  in  paralysis  agitans 
and  chorea,  but  it  markedly  benefits  whooping  cough. 

Moeller,  who  has  made  much  use  of  phenacetin  in 
typhoid  (ever,  states  that  it  does  not  produce  a  durable  and 
constant  apyrexia;  patients  soon  get  accustomed  to  it,  and, 
moreover,  it  has  no  effect  on  the  course  of  the  disease.  This 
clinical  authority  prefers  antipyrin  and  antifebrin  as  antipy- 
retics, but  finds  phenacetin  far  superior  as  an  analgesic.  I  may 
add  that  this  has  been  my  own  experience. 

EXALGIN. 

Still  another  compound  of  apparently  considerable  medi- 
cinal value  (if  we  may  trust  the  statements)  has  been  obtained 
from  one  of  the  products  of  the  destructive  distillation  of  coal- 
tar.  It  has  been  experimented  with  by  several  members  of  the 
Academy  of  Medicine,  who  have  reported  favorably;  and  In 
consequence  of  its  marked  analgesic  properties  It  has  received 
the  name  exalgin. 

At  a  late  me-iting  of  the  Soci6t6  de  Th6rapeutique,  M. 
Bardet  presented  samples  of  this  substance  and  made  his  report. 

Exalgin  represents,  chemically,  methylacetanilide, 
C,H,,N.O  =CeH5C,H,ONCH,.  From  acetanilid  three 
methyllic  derivatives  are  obtained;  one  of  these  is  the  sub- 
stance in  question,  and  is  designated  Ortho-methylacetanllid 
It  presents  itself  In  the  form  of  fine  needles  or  large  white 
tablets,  is  little  soluble  In  cold  water,  more  soluble  In  warm 
water,  and  very  soluble  In  spirit  and  water.  Administered  to 
animals  this  substance  acts  energetically  on  the  cerebrospinal 
axis  and  speedily  kills  In  the  dose  of  40  centigrammes  per  kilo- 
gramme  of  the  weight  of  the  animal.  It  causes  restlessness 
and  trembling,  and  the  respiratory  muscles  soon  become  paral- 
yzed. In  a  less  dose  all  sensibility  to  pain  disappears,  and 
the  temperature  of  the  body  diminishes  gradually. 


:h  this 
I  being 
in  tliat 
le  same 
1  effect 

several 
results, 
used  it 
lervous 
agitans 

etin  in 
ble  and 
it,  and, 
.  This 
antipy- 
I  may 


e  medi- 
tbtained 
of  coal- 
s  of  the 
and  in 
received 

que,  M. 
I  report, 
lanilide, 
d  three 
the  sub- 
:etanilid 
(e  white 
n  warm 
tered  to 
o-spinal 
[>er  Icilo- 
lessness 
le  paral- 
ars,  and 


—   13>   — 

The  physiological  effects  of  exalgin  are  very  similar  to 
those  of  antipyrine,  although  the  former  seems  to  act  in  a 
more  marked  manner  than  aniipyrln  on  the  sensibility,  and 
less  energetically  on  the  heat  centres. 

The  analgesic  effects  of  exalgin  are  obtained  by  a  full 
dose  of  seven  grains;  in  some  instances  it  may  be  necessary 
to  repeat  this  dose  in  a  few  hour?.  The  relief  from  pain  is 
more  prompt  and  more  lasting  than  when  antipyrin  is  given; 
this  is  emphatically  the  case  in  all  forms  of  neuralgia,  especi- 
ally in  the  visceral  neuralgias.  So  far,  no  symptoms  of  gastric 
or  intestinal  irritation  have  been  noted  when  exalgin  has  been 
given  for  its  medicinal  effects;  its  use  has  never  been  attended 
by  cutaneous  eruptions  or  by  cyanosis. 

Exalgin  is  eliminated  by  the  urine,  the  excretion  of 
which  it  seems  to  lessen  in  diabetic  polyuria,  at  the  same  t'me 
that  it  diminishes  the  quantity  of  sugar  in  the  urine. 

ALCOHOL. 

Meuralgic  patients  are  often  benefited  by  various  alco- 
holic preparations  in  moderate,  tonic  doses,  as  an  adjuvant  to 
food  and  exercise.  Wine,  ale,  and  porter  are  the  preferable 
forms;  a  small  glass  of  Bass'  English  ale  or  Dublin  porter 
promotes  appetite  and  general  invigoration.  Alcohol  is  not 
to  be  used  in  neuralgia  for  its  narcotic  effect  as  a  remedy  for 
pain. 

NITRO-GLYCERIN. 

Niiro-glycerin  has  been  recommended  in  some  forms  of 
neuralgia  accompanied  with  pallor,  a  weak  pulse,  small,  rigid 
radial  artery,  etc.  Single  drop  doses  of  a  one  per  cent,  solu- 
tion  (glonoin)  are  given  in  cases  of  small  pulse,  but  with  a 
fu  I  pulse,  the  full  effects  cannot  be  produced  with  less  than 
two-drop  doses  (Trussewitsch).  When,  on  the  other  hand, 
headache  and  neuralgia  occur  in  patients  with  chronic  conges- 
tion of  the  sub:utaneou8  veins  of  the  face  nitro-glycerin  is  to  be 
avoided.*  The  condition  in  which  it  does  the  most  good  is 
one  of  failing  circulation  with  atheromatous  arteries  and  anx- 
mia. 

Nitro-glycerin  seems  to  be  an  exciter  of  the  vaso-dilator 
system  of  circulatory  nerves,  i.  e.,  granting  that  there  are  vaso- 
dilator nerves. 


'Lance/,  Feb.  igtb,  1887,  p,  384, 


_.J 


—     132    — 

V.     Local  Treatment,  etc.     Electricity. 


f  I 


On  account  of  the  similarity  of  action  between  the 
electric  current  and  the  nerve  current,  it  early  oc- 
cured  to  electro-therapeutiats  so  ennploy  electricity  in  neuralgic 
complaints,  with  the  intent  of  modifying  the  molecular  state  of 
the  nerves  and  restoring  the  physiological  function.  Faradism 
was  at  first  almost  the  only  mode  put  in  use,  and  Duchenne  de 
Boulogne  was  one  of  the  nrst  to  make  thorough  trials  of  the 
interrupted  current  in  the  treatment  of  neuralgia.  According 
to  his  reports,  remarkable  success  attended  these  trials.  Since 
that  epoch.  Faradization  has  given  uncertain  results  and  often 
complete  disappointment  in  neuralgic  affections,  and  is  now 
seldom  resorted  to  in  the  treatment  of  any  form  of  neuralgia. 

Faradization  is  believed  to  act  as  a  particular  mode  of 
revulsion  (Vanlair).  Feeble  Faradic  currents  are  utterly  ineflB- 
cacious  in  neuralgia.  In  order,  says  Vanlair,  that  they  may 
manifest  their  curative  active,  they  must  provoke  painful  im- 
pressions.    This  has  been  the  experience  of  other  authorities, 

Mo(/e  of  Application.— k  Kidder,  Mcintosh,  Fleming  or 
Hall  battery  may  be  used,  and  a  pretty  strong  current  em- 
ployed  with  frequent  interruptions;  the  painful  region  to  be 
electrized  by  the  metallic  brush.  This  is  the  method  of  "elec- 
tric fustigalion  "  employed  by  Duchenne  and  Tripier. 

Becquerel  recommended  very  strong  and  rapid  currents. 
He  advised  the  extra  current  and  a  wet  sponge  for  electrode, 
and  directed  to  apply  the  positive  pole  over  the  part  of  the 
nerve  nearest  the  nerve  centre,  and  the  negative  pole  over  the 
divisions  of  the  nerve;  to  be  passed  to  and  fro.  Seances  of 
five  minutes'  duration. 

Vanlair  prefers  the  "dry  excitator,"  which,  correspond- 
ing to  the  negative  pole,  should  be  placed  over  the  painful 
region,  the  other  electrode,  which  may  terminate  in  a  moist 
sponge,  is  placed  a  little  distance  off  The  electrodes  are  not 
moved  back  and  forth  over  the  skin,  i.  e.,  the  current  is  stabile, 
and  not  labile.  Seances  of  five  to  ten  minutes.  When  the 
sedative  action  of  the  current  is  desired,  the  "  moist  excitators" 
are  employed,  the  current  is  given  a  centrifugal  direction 
(positive  pole  central,  negative  pole  peripheral),  and  the 
seances  are  somewhat  longer. 

Galvanism. — All  authorities  are  agreed  as  to  the  necessity 
of  using  mild  currents.  The  negative  pole  is  applied  near  the 
nerve  centre,  the  positive  poie  may  be  moved  over  the  different 


n  the 
ly  oc- 
uralgic 
itate  of 
radistn 
nne  de 
of  the 
:ording 

Since 
i  often 
is  now 
iralgia. 
ode  of 
r  ineflS- 
y  may 
ful  im- 
orities. 
ling  or 
nt  em- 

to  be 
"elec- 

rrents. 
ctrode, 
of  the 
ver  the 
ices  of 

spond- 
painful 
,  moist 
ire  not 
staMe, 
en  the 
tators" 
rection 
nd  the 

icessity 
car  the 
tfferent 


—   '33  — 

painful  points  of  the  affected  nerve.*  When  treating  tic  Jou- 
lourfux.  the  current  should  be  very  mild,  and  should  not  ex- 
ceed three  or  four  milliamperes.f  In  the  case  of  sciatica 
stronger  currents  are  required,  twenty  miliiamperes,  and  even 
more.  The  sittings  should  be  short,  though  according  to 
Apostoli,  the  duration  of  the  seance  cannot  be  fixed  in  advance, 
and  the  passage  af  the  current  should  be  continued  till  the  pain 
disappears,  or  till  at  least  some  mitigation  is  obtained. 

When  tlif-re  is  a  point  douhurtux,  the  positive  pole  may 
be  applied  over  this  point  (Niemeyer,  B^rdet.  Tripier,  Apos- 
tol!).  Static  electricity  is  little  employed  in  neuralgia,  though 
recommended  by  Arthuis. 

With  regard  to  the  choice  of  batteries  when  galvanism  is 
Indicated,  those  principally  in  use  are  the  Daniell  battery  the 
Gaiffe,  the  Bunsen,  the  Siemens-Halslce,  and  the  Lcclanch* 
battery. 

Among  the  advantages  of  galvanism  over  faradism  in 
neuralgia,  are  the  following: 

1.  It  is  not  painful,  or  scarcely  at  all  painful. 

2.  It  exercises  a  decidedly  sedative  effect  when  applied 
ucunJum  artem.  A  notable  depression  of  the  sensibility  and 
motility  of  the  nerve  follows. 

3-  It  has  the  property  of  acting  on  the  nutrition  of  the 
tissues  in  energizing  the  exchange  of  materials.  This  is  the 
catalytic  effect  of  the  current,  called  eleetrolysis.X 

According  to  Eulenburg,  sciatica,  of  all  the  neuralgias,  is 
that  which  most  readily  yields  to  the  constant  current,  while 
intercostal  neuralgia,  (so  amenable,  according  to  this  authority 
to  faradism)  resists  the  action  of  the  galvanic  current 

Migraine,  according  to  Dr.  Joseph  Stead.g  is  almost 
always  benefited  by  the  constant  current.  He  cites  cases 
where  a  five  minutes  application  of  a  galvanic  current  pro- 
duced  most  gratifying  results.  The  battery  used  was  that  of 
Weiss.  He  employed  about  eight  cells  with  very  small 
sponges  (about  as  large  as  would  fill  the  end  of  a  thimble) 
soaked  in  warm  water,  and  fixed  to  those  small  conical  elec- 
trodes which  are  used  for  the  localization  of  the  current  in 
paralysis  of  the  interossei  and  lumbricales  muscles.      He  ap- 


J Djij^din-Beaumeti,  ainical  Thtr,p,uih,,  Am.  ed. 

I  Vanlair,  loc.  cil.,  p.  aoo. 

i  Braithwaite's  Retrospect,  Pan  65.  page  86. 


p.  59. 


■:'  ! 


—   'J4  — 

piled  them  over  the  painful  rcKlon,  keeping  them  about  on« 
inch  apart,  moving  ihcm  about,  but  not  removinR  them  for 
two  ninnihR.  As  soon  as  the  pain  ceases  in  a  case  of  neu- 
ralKia,  he  makes  it  a  rule  to  discontinue  the  application. 

Dr.  S.  J.  Knoll,  in  l.omlon  /.ancft,  Dec.  iSih,  1875,  rcporti 
several  very  inlereslinK  cases  ii(  sciatica  cn.rtil  by  Ralvanism. 
He  used  eighteen  cells  of  SlWhrers  battery;  seances  three  times 
a  week. 

Another  writer  who  has  made  much  use  of  galvanism  in 
the  treatment  of  neuralgia  is  Dr.  J.  Russell  Reynolds,  to  whose 
valuable  articles  in  the  /.(/«(,  (2(1  part,  iH7*>)  we  can  only  just 
allude.  The  same  may  be  said  of  Dr.  A.  D  Rorkwell.  of  New 
York,  and  Dr.  Henry  Lawson  of  St.  Mary's  Mospital,  London. 

MASSACIE.  — KINRSirilKKAI'V. 


'!i 


Kinesitherapy  is  the  treatment  of  diseases  by  movement, 
and  includes  gymnastic  exercises,  Swedish  movement,  and 
massage. 

One  would  never  resort  to  the  "movement  cure"  or 
massage  during  a  neuralgic  paroxysm,  except  so  f.i-  as  he 
might  endeavor  by  gentle  frictions  01  steady  compressi  .n  over 
the  aflectcd  nerve  or  nerves  to  attenuate  the  pain.  So.netimes 
such  manipulations  are  attended  with  signal  benefit,  while  on 
other  occasions  all  pressure  and  movement  aggravate  the 
suffering. 

Valleix  has  noticed  that  pressure  diminishes  certain  neu- 
ralgic pains,  and  the  authors  of  the  Compendium  o(  Medicine 
speak  of  facial  neuralgias  calmed  by  methodical  compression 
over  the  trunk  of  the  nerve.*  In  a  recent  publication,  Gassen- 
baur  relates  two  cases  of  rebellious  neuralgia  treated  by  mas- 
sage.f  The  one  was  a  sciatic,  the  other  a  crural  neuralgia. 
From  his  own  researches,  Faye  concludes  that  massage  is  ad- 
vantageous in  acute  and  well  circumscribed  idiopathic  neu- 
ralgia, and  notably  in  sciatica,  facial  neuralgia,  and  neuralgias 
of  the  perineal  region.    It  has  but  a  feeble  action  in  migraine. | 

The  Swedish  treatment  of  neuralgia  consists  in  deep 
kneading  of  the  entire  limb  or  portion  os  the  body  aflected. 
Deep  pressure,  for  instance,  is  made  with  one  finger  or  thumb 


I 


•  V'anlair,  Loc.  cit.,  p.  aja. 
t  Vanlair,  Loc.  cit.,  p.  m. 
%  Cited  by  Vanlair. 


miSm 


)ut  one 
cm  (or 
)f  neu- 

reporti 
^anlsm. 
;  times 

nism  In 
>  whose 
ily  just 
3(  New 
ondon. 


'cment, 
t,    and 

irc  "  or 
!  as  he 
■n  over 
netimes 
hile  on 
Die   the 

in  neu> 
edicine 
iresslon 
jassen- 
ly  mas- 
jralgia. 

is  ad- 
ic  neu- 
iralgias 
!r<>ine.| 
n  deep 
ffected. 

thumb 


—   '.KS  — 

on  the  nerve  at  the  fieat  of  puin,  which  rauwes  un  intense  pain 
for  the  moment,  l)ut  Is  followed  l)y  a  sort  of  paralvsis  of  the 
same  nerve,  lastinK  for  several  hours.  In  neiiralKJc  alTrctioris 
of  the  ulnar,  pcrcu'sioti  is  iiKule  aloiij;  thin  nerve  from  lis 
oriKin  to  its  ti-rmination.  '  Thf  IjIows  shouM  be  sharp  and 
short  l(  the  pain  is  a  dull,  heavy  arhr,  and  of  the  chararlir  of 
a  slow  he.ivy  pressure  if  the  pain  is  arute.  For  insi.imc,  in 
facial  ncuralKia,  paralyze  the  trigeminus  trunk  to  (Ut  off  Its 
sensation,  then  kne.nl  and  percuss  with  the  finder  lips." 

Minute  dirertioiiN  after  this  pattern  are  Riven  in  many 
treatises;  il  Is  not,  however,  prol)al)le  that  m  issa^e  will  ever 
have  a  wide  field  of  usefulness  In  the  treaimeni  of  neuralgia. 
Much  more  can  be  expecleil  of  Kymnastirs  in  the  prophylaxis 
of  neuralgia,  for  the  exercises  included  under  this  head  have  a 
directly  fortifying  effect  on  the  general  muscular  system,  on 
the  nerves  and  nerve  centres.  Besides,  as  Anstie  points  out, 
gymnastics  not  only  improve  the  circulation  and  general 
nutrition,  including  the  nutrition  of  the  nervous  centres,  they 
also  give  the  nervous  centres  an  education  by  the  variety  of 
dilUcult  co-ordinativc  movements  over  which  it  trains  those 
centres  to  preside.* 

COUNTER-IRRITATION.— RKVULSIVKS. 

In  my  judgement,  counter  irritants  (as  mustard,  turpen- 
tine, acetic  acid,  oil  of  cajeiput)  have  not  a  very  important  place 
in  the  therapeutics  of  neuralgia.  I  have  never  seen  a  severe 
case  of  intercostal,  rervico-brathial,  sciatic  or  other  pure  neu- 
ralgia much  relieved  by  a  mustard  plaster  or  a  turpentine 
stupe,  I  believe  that  it  is  in  rheumatoid  pains  and  in  myalgia 
that  these  applications  principally  do  good,  Severe  revulsion 
by  vesicants,  the  actual  cautery,  the  thermo-cautery,  has,  how- 
ever, in  many  severeformsof  chronic  neuralgia  been  productive 
of  benefit. 

I  remember  a  bad  case  of  cervico-brachlal  neuralgia 
where  pusiulation  by  tartar  emetic  ointment  over  the  upper 
part  of  the  spine  caused  a  marked  pos.ponement  of  the  ordi- 
nary attacks.  In  sciatica,  I  have  occisionally  seen  good  from 
blisters  applied  along  the  nerve,  over  the  seat  of  pain. 

Latterly,  the  chloride  of  methyl  spray  has  proved  the 
most  efficacious  means  of  treating  sciatica.    A  peculiar  appara- 


'  An^tic,  on  Neuralgia,  Am.  ICd.,  p.  175. 


V  IJ 


n 


—  136  — 

tus  is  required  for  these  pulverizations,  which  produce  intense 
cold,  followed  by  marked  revulsion.  A  description  of  this  pro- 
cess will  be  found  in  New  Medications,  Am.  Ed.,  page  283. 

Cauterizations  have  been  employed  in  very  obstinate 
cases.  Legroux  was  in  the  habit  of  employing  sulphuric  acid 
in  the  treatment  of  sciatica;  with  a  stick  soaked  in  the  strong 
acid,  he  marked  out  on  the  painful  member  the  branches  of  the 
sciatic  nerve.  At  the  present  day,  the  hot  iron,  and  especially 
the  Paquelin  cautery  are  used:  with  this  cautery,  points  are 
made  all  along  the  nerve.  Acupuncture  is  another  means  of 
revulsion,  now,  however,  pretty  much  gone  out  of  vogue.  The 
same  may  be  said  of  Baunscheidt's  r^veilleur  de  la  vie,  a  little 
apparatus  consisting  of  a  bunch  of  pins,  made  to  penetrate  the 
skin  by  a  spring;  these  pins  were  generally  dippf-d  in  croton 
oil  before  using  the  instrument. 

Dujardin-Beaumetz*  refers  to  the  benefits  so-:  'times  de- 
rived from  electro-puncture,  as  performed  with  tht  condenser 
of  Plantfe  appropriated  by  Trouve  to  medical  practice.  With 
a  wire  heated  to  a  red  heat  by  electricity,  points  are  made  to 
the  depth  of  a  half  a  centimetre,  and  some  little  distance  apart, 
over  the  tract  of  the  affected  nerve.  The  punctures  are 
followed  by  considerable  inflammation,  but  they  often  bring 
the  greatest  relief  to  the  patient. 


I 


HYPNOTIC   SUGGESTION. 


ill 


1;! 


Of  late  many  remarkable  cures  have  been  claimed  by 
hypnotic  suggestion.  The  subject  is  thrown  into  the  hypnotic 
or  mesmeric  sleep,  and  the  suggestion  is  repeatedly  made  till 
it  proves  to  be  o.  reality  that  the  pain  is  all  gone.  Bernheim 
has  related  in  his  book:  "  De  la  Suggestion  et  de  set  applications 
h  la  thirapeutique"  facts  of  this  kind.  The  pain  of  migraine, 
sciatica,  pleurodynia,  etc.,  has  been  caused  to  disappear  by  a 
profound  impression  made  on  the  sensory  nerve  centres  of  the 
subject.  It  would  appear  that  under  hypnotism  the  higher  cor- 
tical centres  are  dormant,  and  that  in  a  certain  proportion  of 
cases,  the  functional  activity  of  sensori-motor  ganglia  that  are 
in  a  state  of  morbid  irritation  may  be  suspended  by  sugges- 
tion. But  the  modus  operandi  ol  the  process  is  involved  in  pro- 
found obscurity. 


;?ii 


*  Clinical  Therapeutics,  Am.  Ed.,  p.  66 


n  tense 
s  pro- 

83- 

itinate 
c  acid 
strong 
of  the 
ecially 
ts  are 
ins  of 
.  The 
I  little 
te  the 
croton 

es  de- 
Jenser 

With 
ide  to 
apart, 
;s  are 

bring 


ed  by 
pnotic 
ide  till 
nheim 
caftans 
;raine, 
r  by  a 
of  the 
tr  cor- 
tion  of 
lat  are 
ugges- 
n  pro- 


—   137   — 

NERVE   STRETCHIN«S. 

Nussbaum  was  the  first  to  practice  nerve  stretching: 
Billroth  about  the  same  epoch  (in  1872)  performed  this  opera- 
tion. It  has  since  been  performed  in  England,  Germany, 
France,  and  America.  From  Chauvit's  article  ("On  Nerve 
Stretching,"  Arch.  Gen.  de  Med.,  1881,  p.  701-710)  we  ascertain 
that  in  188 1  nerve  stretching  has  been  employed  in  fifty-two 
cases  of  neuralgia,  as  follows: 

Neuraltriaof  the  face 14 

Intestinal  neuralgia 2 

Neuralgias  of  the  upper  extremities 9 

Neuralgias  of  the  lower  extremities 2j 

In  these  fifty-two  cases  of  neuralgia  there  were  thirty 
complete  cures,  twelve  cases  where  there  was  marked  amelior- 
ation, and  ten  failures.* 

According  to  Dujardin-Beaumetz,  the  benefits  obtained 
in  some  instances  from  nerve  stretching  may  be  thus  explained: 
It  is  probable  that  "the  stretched  nerves  have  a  reactive  in- 
fluence on  the  sensory  spinal  centres  which  favorably  modifies 
the  molecular  state  of  the  cells;  this  view  receives  support  from 
the  fact  that  very  powerful  tractions  do  the  most  good."  The 
elongation  does  not  act  by  causing  a  solution  of  continuity  in 
the  nerve  fibres.  In  fact,  according  to  the  observations  of 
Davalt,  the  sensibility  returns  at  the  end  of  twenty-four  hours, 
which  would  not  be  possible  were  there  a  rupture  of  the  nerve 
filaments. 

In  one  of  Cox's  cases  the  ulnar  nerve  was  stretched  for  a 
traumatic  neuralgia;  the  operation  resulted  in  a  cure.  Both 
supra-orbital  and  infra-orbital  nerves  have  been  stretched  for 
obstinate  pain  located  in  their  tracts,  and  other  branches  of 
the  fifth  nerve  have  been  stretched,  with  variable  results.  Sci- 
atica has  been  sometimes  benefited  by  the  operation. 

The  nerve  is  cut  down  upon  in  the  most  exposed  place, 
lifted  out  with  the  forefinger  and  pulled  upon  with  a  force  of 
forty  to  fifty  pounds. 

NEUROTOMY. 

Neurotomy  was  performed  for  the  first  time  by  Marichal, 
more  than  a  century  ago,  for  neuralgia,  and  has  since  been 
repeated  in  a  multitude  of  instances. 

♦  Clinical  Thtraptuticty  Am.  Ed.  (Detroit),  p.  63. 


-  138  - 

It  cannot  be  denied  that  marked  relief  has  in  many  cases 
been  obtained  by  simple  section  of  painful  nerves,  though  the 
results  are  generally  temporary  and  disappointing.  That  this  is 
likely  to  be  the  case  is  apparent  from  the  following  considera- 
tions: I.  It  may  be  difficult,  If  not  impossible,  to  reach  the 
suffering  nerve  when  it  is  situated  deeply.  2,  The  seat  of  the 
pain  may  really  be  central  and  not  peripheral.  The  sensory, 
cortical,  ganglia  may  be  affected,  and  the  pain  referred  to  the 
peripheral  branch;  in  this  event  section  of  the  nerve  might 
fail  in  ;>ny  way  to  modify  the  encephalic  centre,  although  some 
brilliant  results  have  been  recorded  from  neurectomy  in  cases 
where  the  neuralgia  was  of  purely  centric  origin.  Here  the 
strong  peripheric  stimulus  of  the  operation  has  acted  as  an 
energetic  nervous  alterant.  Instances  of  this  kind  are  re- 
corded by  Erb  In  Zlemssen's  Cyclopaedia,  Vol.  XI.,  page  95. 
3.  Another  objection  to  nerve  section  is  the  trophic  disturb- 
ances which  are  likely  to  follow;  this  is  especially  the  case 
when  a  mixed  nerve  has  been  severed. 

On  account  of  the  partial  and  fleeting  success  which  has 
attended  neurotomy,  the  favorite  operation  is  now: 

NEURECTOMY. 

Here  a  portion  is  exsected  from  the  painful  nerve.  Repair 
eventually  takes  place,  and  the  nerve  resumes  its  functions, 
but  respite  from  pain  for  a  considerable  time  is  obtained,  and 
during  the  period  of  formation  of  new  nerve  tissue  and  re- 
establishment  of  conduction  by  union  of  the  divided  nerve  > 
ends,  it  is  hoped  that  restoration  of  the  normal  condition  in 
the  diseased  foc^s  may  be  established. 

Neurectomy  is  hardly  practicable  except  in  neuralgias  of 
the  trigeminus,  and  not  more  than  about  two  centimetres  of 
the  diseased  nerve  ought  to  be  excised. 

Neurectomy  of  the  fifth  nerve  was  performed  more  than 
fifty  years  ago  by  the  late  Dr.  Joseph  Pancoast,  of  Philadel- 
phia, who  was  the  first  to  reach  the  interior  maxillary  nerve 
by  sawing  through  the  condyle,  and  to  cut  it  close  to  the  fora- 
men ovale.  Dr.  W.  H.  Pancoast,  son  of  the  former,  has  made 
several  exsectlons  of  the  sciatic  and  crural  nerves  in  obstinate 
neuralgias.  Neurectomy  of  these  latter  nerves,  however,  is 
generally  considered  a  dangerous  and  u/isatisfactory  operation 
as  they  are  mixed  nerves,  and  both  trophic  and  motor  paralyses 
are  sure  to  follow  the  operation.  Hooker  practiced  exsection 
of  the  popliteal  in  one  desperate  case;  for  three  months  there 
was  absence  of  all  pain. 


i  cases 
gh  the 
t  this  is 
sidera- 
ch  the 
of  the 
nsory, 
to  the 
might 
1  some 
I  cases 
re  the 
as  an 
ire  re- 
ge  95- 
isturb- 
e  case 

ch  has 


Repair 
ctions, 
id,  and 
,nd  re- 
nerve  • 
ion   in 

gias  of 
itres  of 

e  than 
liladel- 
nerve 
e  fora- 
5  made 
stinate 
ver,  is 
eration 
ralyses 
section 
I  there 


—   ^39    - 

Dr.  Maurice  H.  Richardson,  of  the  Massachusetts  Gen- 
eral Hospital,  has  practiced  exsection  of  the  inferior  dental 
nerve  with  brilliant  results.  This  nerve  is  comparatively  easy 
of  access.  In  1876  the  first  operation  for  avulsion  and  de- 
struction of  the  whole  nerve  was  performed,  and  this  operation 
has  been  several  times  repeated  since  then.  The  buccal  nerve 
has  been  in  several  instances  divided  where  it  comes  out  over  the 
buccinator,  and  the  superior  maxillary  nerve  has  been  exsected 
in  the  floor  of  the  orbit.  Dujardin-Beaumetz  alludes  to  a  case 
occurring  under  his  care  in  St.  Antoine  Hospital.*  The  pa- 
tient <i  as  a  sufferer  from  tic  douloureux.  All  medical  means 
had  been  un;\vailing.  It  was  an  infra-orbital  neuralgia. 
Beaumetz  advised  resection  of  the  upper  maxillary  nerve;  the 
operation  was  performed  by  Terrillon.  The  nerve  was  sought 
at  its  point  of  emergence  from  the  foramen,  and  followed  into 
the  floor  of  the  orbit;  the  terminal  portion  of  the  nerve  to  the 
extent  of  three  centimetres  was  excised.  Two  years  had 
elapsed  at  the  time  of  the  writing;  the  pain  had  never  returned. 

But  the  operation  is  seldom  so  successful,  and,  as  Beau- 
metz remarks,  many  instances  are  on  record  where  branches 
of  the  trifacial  have  been  resected  for  painful  affections,  and 
with  the  utmost  skill  and  thoroughness,  with  no  result  but 
aggravation  of  pain  to  the  patient  and  mortification  to  the  sur- 
geon. This,  as  before  sdid,  is  especially  apt  to  be  the  case 
where  the  pain  is  central;  and  it  must  be  remembered,  too, 
that  much  of  the  neuralgia  that  one  ordinarily  sees  is  consti- 
tutional or  dyscrasic,  t.  e. ,  due  to  morbid  alterations  of  the 
blood;  it  is  not  to  be  expected  that  such  neuralgias  would  be 
mjterially  benefited  by  any  operation  on  the  nerves. 

HYDROTHERAPY. 

Doubtless  the  external  action  of  cold  water  in  the  form  of 
douches,  jet;,  the  shower  bath,  the  cold  plunge,  sea  bathing, 
is  of  prime  utility  in  toughening  the  integument  and  strength- 
ening the  peripheral  nerves  of  neuralgic  persons.  Fleury  has 
applied  with  success  the  cold  douche  to  recent  trifacial,  inter- 
costal, and  sciatic  neuralgias.  He  has  seen  the  pain  disappear 
after  two  or  three  treatments.  Intercostal  neuralgia  is  the  most 
amenable  to  the  cold  douche.  He  records  that  the  first  applica- 
tions are  likely  to  exasperate  the  pains,  b.it  perseverance  brings 
its  reward. 


*  Clinical  Therapeutics,  Detroit  ed.,  page  It. 


tT?ji&^^^^jMa?iljn:.w,^jgE;^ii.^r,>ijj.  iH,^j,j;gct^OT.j^W*.;.Baf^ff3g-^^wyf*Wg?' 


—  140  — 

At  the  hydrotherapic  establis'iments  there  is  a.  variety  of 
appliance^  for  cold  water  treatment  {douche  en  jet  mobile,  douche 
en  lame,  douche  en  pluic,  douche  en  cercle,  etc.),  all  of  which 
must  be  dispensed  with  in  private  and  ordinary  hospital  prac- 
tice. It  has  not  even  been  proved  that  the  wet  pack  is  of  any 
utility  in  the  neuralgias  of  the  trunk  or  viscera. 

It  would  appear  that  the  principal  benefit  to  be  derived 
from  hydrotherapy  is  of  a  prophylactic  kind,  and  that  the  cold 
douche  is  principally  of  use  (like  cold  bathing  and  sea  bathing) 
in  strengthening  weak  organisms. 

Nevertheless,  some  authorities  (notably  Baruch)  speak  in 
unqualified  terms  of  the  benefits  of  hydropathy  in  various 
forms  of  neuralgia.  Baruch  has  found  it  especially  serviceable 
in  sciatica.  The  patient  is  wrapped  in  a  dry  woolen  blanket; 
pieces  of  old  woolen  blanket  two  and  four  feet,  doubled,  are 
wrung  out  of  hot  water  by  means  of  a  wringer.  These,  after 
liftfng  the  blanket,  are  applied  to  the  affected  limb  over  the 
region  of  the  nerve,  and  are  rapidly  changed  till  the  parts  be- 
come thoroughly  congested  and  the  patient  is  bathed  in  per- 
spiration. This  treatment  is  kept  up  about  half  an  hour.  In 
chronic  cases  the  general  tonic  treatment  by  cold  ablutions, 
douches,  and  plunges  is  indicated. 

OSMIC  ACID. 

Osmic  acid  is  a  tetroxide  of  osmium.  It  is  colorless,  solid, 
crystallizable  in  long,  brilliant,  flexible  prisms,  melts  at  40°  C. 
and  volatilized  at  100°  C.  It  exhales  a  very  pungent  horse- 
radish odor,  and  its  vapors  are  very  irritant. 

This  substance  was  first  introduced  into  the  therapeu- 
tics of  neuralgia  by  Eulenberg,  who  treated  with  success  cer- 
tain neuralgias  by  hypodermic  injections  of  osmic  acid,  a  one 
per  cent,  solution  in  distilled  water.  He  found  that  the  injec- 
tions of  the  above  strength  caused  no  unpleasant  symptoms. 
He  selected  twelve  cases  of  neuralgia  in  different  cutaneous 
nerve  districts  of  the  upper  and  lower  extremities  of  the  head 
and  body;  most  of  these  were  fresh  and  not  unusually  severe 
cases.  The  treatment  extended  over  one  to  six  weeks;  the 
number  of  injections  in  individual  cases  was  from  three  to 
fourteen.  The  amount  injected  was  a  half  a  gramme  of  the 
solution;  the  injection  was  made  into  the  diseased  part.  Of 
twelve  cases  three  were  cured,  four  more  or  less  relieved;  five 
were  not  benefited. 


fei.. 


y  of 
4che 
lich 
rac- 
any 

ved 
:old 
Ing) 

c  in 
ous 
ible 
ket; 
are 
iter 
the 
be- 
per- 
In 
>ns, 


)lid. 

•c. 

rse- 

>eu- 
cer- 
one 
jec- 
ms. 

lOUS 

lead 
rere 
the 
;  to 
the 
Of 
five 


—   141   — 

More  recently,  Shapiro,  of  St.  Petersburg,  has  reported 
success  with  the  subcutaneous  use  of  osmic  acid  in  facial  neu- 
ralgia.  The  commencing  dose  was  five  drops.  He  had  not 
observed  any  evil  local  effects  from  these  injections.  He  re- 
marks  that  the  most  important  action  of  the  drug  is  to  cause 
inflammation  of  the  terminal  nerve  branches,  its  narcotic  effect 
bemg  of  a  secondary  nature  only. 

Dr.  G.  W.  Jacoby,  of  New  York,  claims  to  have  treated 
eighteen  cases,  mostly  of  sciatica,  by  these  injections,  eight  of 
which  were  cured,  and  some  others  benefited. 

Dr.  Merces  {Lancet,  Jan.  loth,  1885)  reports  having  tried 
osmic  acid  in  eighteen  cases  of  sciatica.  The  patient's  ages 
varied  from  eighteen  to  sixty.five.  In  twelve  cases,  he  suc- 
ceeded in  giving  absolute  relief  for  a  period  of  three  weeks 
when  he  lost  sight  of  them.  In  six  he  gave  temporary  relief! 
The  injections  were  as  many  as  twelve  in  one  case.  He  says 
that  although  he  gave  theoe  patients  no  permanent  relief,  they 
obtained  more  comfort  from  the  osmic  acid  than  from  even 
hypodermic  injections  of  morphine.  He  used  a  one  per  cent, 
solution,  injecting  from  three  to  five  minims  deeply  over  the 
sciatic  nerve.  At  the  seat  of  the  puncture  the  patient  com- 
plained of  a  numb  feeling,  which,  however,  was  transient.  In 
some  cases  the  effect  was  marvellous,  the  patient  being  able 
after  a  short  time  to  stand  on  the  affected  leg,  a  feat  which 
he  had  been  unable  to  do  before  for  years.  He  thinks  the 
effects  are  "undoubtedly  local,"  but  does  not  believe  that  it 
exerts  its  action  by  setting  up  an  inflammation,  but  rather 
by  a  narcotic  effect.* 

VERATRIA. 

There  is  some  testimony  in  favor  of  veratria  ointment, 
f>R  an  adjunct  to  other  treatment,  in  migraine,  supra-orbiul  and 
intercostal  and  other  neuralgias.  Anstie  has  seen  it  do  much 
good  in  mammary  neuralgia. 

The  following  preparations  are  in  vogue: 

PoMMADE  CoNTRE  Neuralgies. — (Bertrand.) 


M. 


Veratrin,  o  gramme  30  centig:r. 
Muriate  of  morphia ,  o.  ij^ramme  ao  centiirr 
Glycerite  of  starch,  30  gr, 


*Dujardia-Beaumetz,  Did.  dt  Thir.    Art.;  O^mic  Acid 

2*^. '''!  r*^i-  ,9"?  P-  '^^^  Lancet,  July  95th,  1885;  p.  167. 
Medical  Record,  Vol.  xxvii;  p.  713.        '    »    '      ».  1^  »  7. 


—     142    — 

Pomade  de  Veratrin. — (Dujardin-Beaumetz.) 

Veratrin,  o.  Kramme.  oscentigr. 
Axunge,  lo. 

It*' 

Veratria  Ointment.— 

Veratria,  3i. 
Lard,   Ji. 

M.  Kor  ordinary  use  in  neuralgia  this  ointment  should  be  diluted 
with  as  much,  or  twice  as  much,  lard. 

PHENIC  ACID   IN   HYPODERMIC   INJECTIONS. 

Recently  Baccelli  (Semaine  Medical,  1888,  p.  422,  and 
1890,  p.  xxiv.)  has  lauded  the  use  of  phenic  acid  in  subcu- 
taneous injections  in  neuralgias  in  general,  and  particularly  in 
sciatic,  supra-orbital,  and  intercostal  neuralgias.  In  the  Se- 
maine Medical  for  February  6,  1890,  he  reports  a  c— i  of  tela- 
nus  cured  by  this  means.  Baccelli  employs  a  i  per  cent,  so- 
lution of  phenic  acid;  the  injections  are  made  over  the  si.»t  of 
pain.  The  injections  are  repeated  every  hour  till  relief  is  ob- 
tained;  at  first  one-sixth  grain  of  the  active  substance,  then 
two-sixths,  by  injection.  According  to  this  writer,  the  efficacy 
of  phenic  acid  is  due  to  the  sedative  action  which  this  medica- 
ment exerts  on  the  excitability  of  the  nervous  centres.  But 
little  pain  or  smarting  follows  these  injections. 

CONCLUSION. 

The  medical  student  and  the  junior  practitioner  who 
know  little  of  neuralgias  except  what  they  have  learned  in 
books,  may  imagine  from  the  above  formidable  list  of  remedies 
that  with  such  a  therapeutic  arsenal  they  may  easily  triumph 
over  every  form  of  pain.  Alas!  how  soon  will  they  find  their 
mistake!  This  very  abundance  of  therapeutic  resources  shows 
the  intractableness  of  the  painful  neuroses.  It  were  to  be 
wished  that  we  had  fewer  medicaments,  and  better. 

At  the  same  time,  the  medical  profession  is  far  better 
able  to  cope  with  diseases,  whose  principal  element  is  pain,  at 
the  present  day  than  ever  before  in  the  past.  Think  of  the 
physician  of  former  times,  with  no  analgesic  medicines  but 
crude  opium  and  other  narcotics;  without  any  knowledge  of 
the  surgical  means! 


ii 


liluted 


r,  and 
ubcu- 
rly  in 
e  Se- 

teta- 
It.  so- 
i^^t  of 
is  ob- 

then 

Bcacy 

edica- 

But 


r  who 
led  in 
aedies 
lumph 
I  their 
shows 
to  be 


—   143  — 

Since  the  last  edition  of  Anstie's  worlc (October.  i87i)and 
that  of  Vanlair  (1882),  all  the  so-called  analgesics  (antjpyrin, 
exalgin,  acetanilid,  etc.),  have  been  discovered;  cocaine  has 
come  into  general  use  as  a  local  anaesthetic;  several  new  and 
valuable  hypnotics  (paraldehyd,  sulphonal,  chloralamid,  etc.) 
have  been  introduced;  hypnotic  suggestion  has  been  brought 
into  prominence,  and  has  won  some  triumphs  in  the  realm  of 
obstinate  neuralgias,  and  Hygienic  therapeutics,  which  includes 
massage,  gymnastics,  the  Swedish  movement  cure,  hydrother- 
apy, aerotherapy,  climatotherapy,  dietetics,  etc. ,  have  under- 
gone considerable  development. 

Yet,  despite  progress  in  neurology,  in  pathology,  in 
therapeutics,  the  physician  must  still  often  find  himself  power- 
less before  a  stubborn  case— powerless  to  contend  against  the 
forces  of  heredity,  powerless  to  right  an  organism  that  has 
always  been  wrongly  constituted. 

It  is  to  be  lamented  that  we  have  not  more  precise  indica- 
tions as  to  the  uses  of  most  of  the  drugs  mentioned  above, 
whose  employment  must  be  still  largely  empirical.  Nor  can  it 
yet  be  said  that  we  have  for  the  various  forms  of  neuralgia  cer- 
tain specifics  on  which  we  can  depend,  so  that  one  may  affirm 
that  in  this  kind  of  pain  phenacetin  is  especially  applicable,  in 
that  acetanilid,  etc.  The  physician  will  often  be  compelled  to 
feel  his  way  along  by  the  help  of  somewhat  vague  lights,  and 
no  text-book  or  treatise  can  do  more  than  give  him  hints  which 
he  may  tentatively  apply  to  each  particular  case. 


better 
tin,  at 
of  the 
!8  but 
dge  of 


i 


4^- 


INDEX. 


A  Page. 

Abbe,  Dr.  Robt ^j 

Abscess,  Cerebral ^ 

Acetanilid  (Ami(ebrin) ,02    128 

in  Migraine ^g 

Aconite ... 

114 

Aconitia  (Aconitine) ic,  114 

in  Migiaine ^g 

Age  as  a  Predisposing  Cause js 

Albuminuric  Neuralgia 

Alcohol  in  Neuralgia ,,, 

Ammonium  Chlorid*'  in  Neuralgia ,22 

Anaimic  Neuralgias. g. 

AniBsthetics  in  Nt-uralgia ,,. 

Analgesics ■'■■  j^^ 

Angina  Pectoris , 

Treatment  of ^d,  69 

Angio-Paralytic  Migraine .^ 

Angio  Spastic  Migraine..     .^ 

A'-'ipyrin ".'.l".'."."'.""io2;  124 

in  Ovarian  Neuralgia 5, 

Migraine ,g 

Sciatica ,g 

Injections  of j^^ 

Anstie,  ..5,  25,  35.  39,  42,  43,  51,  60,  63,  64,  100,  in,  V18.  nq 

•ao,  121,  123 
Appendix j^^ 

A""''= '.".'.100.  H9 

Atheroma  as  a  Cause  of  Neu.algia -q 

Atropine '"""!!.!!!!!!!  iio 


"1 

II 

ill 
(_ 


_   146  — 

B.  P*B«- 

BacriUl '** 

Bartholow 

Belladonna . 

Bernheim 

Blisters  in  Intercostal  Neuralgia 47 

Sciatica " 

Brodle  '* 

Bromide  of  Potassium '" 

Bromo-Pyrine  and  Bromo-Cafleine '03 

Buzzard ^' 

_  „  ,  109,  ia6 

Caffeine _ 

in  Migraine ^o 

117 

Camphor-Chloral 

Cannabis  Indica 

in  Migraine 3" 

Carnochan's  Operation 34 

Cautery,  Actual  in  Sciatica " 

Cauterizations 

Cervico-Occipital  Neuralgia ^i 

Cimiclfuga  Racemosa  in  Ovarian  Neuralgia «>» 

Chloride  of  Methyl  In  Sciatica 5* 

Chloral JJJ 

Chloroform ■'  ^  . 

Injections 55.  106.  116 

Chlorodyne  and  Chlor-Anodyne 5o8 

Chlorotic  Neuralgias ^^J 

Cocaine 

Coccydynia ^ 

Cod-Liver  Oil '°°'  "J 

Cohen '"' 

Cold  as  a  Cause  of  Neuralgia »5,  ^"9 

Conium  Maculatum 


!': 


A 


^fl 


Page. 
..  ua 
..  56 
, . .  no 
, ..  136 
...  47 
...  55 
...  89 
...  117 
. . .  103 
...  49 

[03,  136 

..  38 

...  117 

.  .  .  Ill 

...  38 

...     34 
....     55 

....  135 
....  4t 
. . . .  61 
. . . .  54 
....  117 
....  116 
106,  116 

508 

. . . .  81 
....  118 
...  49 
ICO,  133 

I30 

..15,     39 
119 


—  M7  — 

Cooper  on  Treatment  of  Mastodynia .g 

Counter  Irritation '"  ,,, 

Co'ugno ........!...!!.'.'!  lio  « 

Croton   Chloral _  '  ," 

D. 

Diagnosis g 

Diatheses,  Treatment  of 100 

Diabetic  Neuralgia 78 

Du  Bois-Reymond 

Dujardin-Beaumetz 46,  53,  54,  61,  115,  137.  136,  137,  139 

Electricity  in  Neuralgia '. ,3^ 

l'^"  :•■■:'". '7,47.51.53,55.77.     91 

Ergot  in  Migraine -g 

Ergotic  Neuralgia gj 

Erlenmcyer 

Ether  in  Neuralgia ]     ,  ,g 

Etiology  of  Neuralgia j . 

^"'"""'^ ;.'".";.';36."37,  39 

E**'*'" 102,  130 

Exciting  Causes  of  Neuralgia 27,  38 

Eyestrain  as  a  Factor  in  Neuralgia .'  73 

F. 

Faradization j.^ 

in  Sciatica . - 

Fothergill's  Pill ...!!..!.....     99 

Fowler's  Solution  in  Neuralgia ,00 

G. 

<^a'''»n''"n 100,  133 

in  Gastralgia 5 . 

Gastralgia "...".".".".  V.  .63'.  63 

Celsemium j 

in  Migraine -g 


i 

I 


A 


J 


T' 


148  — 


Gowen 

Gouty  Neuralgia 

Gross'  NeuralKic  PiUi 

Guaiacum  in  Dysmenorrhoea. 

Guarana 

In  Migraine  

Gueneau  de  Mussy 


.«,  II,  71.     03 

76 

113 

60 

136 

3» 


.104, 


H. 


Hammond 

his  Ferruginous  Tonic. 

Hashish 

Hemlcrnnia 

Heredity  as  a  Cause  o(  Neuralgia. . 
Hepatalgia 


5f'. 


S« 


133 
133 
III 

35 
34 
6a 

35 


Hesse ^ 

Huchard  on  Angina  Pectorli 

Hydrotherapy ^ 

Hydrastis  Canadensis 

Hygienic  Therapeutics 9 

Hypnotism '°-*'  '^^ 

Hypnotics 

Hyoscyamus 

Hyperalgesia 

HyBteralgIa 

Hysterical  Joint* 

Neuralgia 

I. 

Indian  Hemp  (see  Cannabis) '" 

Treatment  of  Migraine  by i" 

Iodide  of  Sodium  in  Angina  Pectoris 70 

Iodide  of  Potassium  in  Sciatica 5 

Iron  in  Neuralgia 


113 

10 

59 
89 
80 


PaRC. 

93 

7ft 

4. 

"3 

6o 

136 

38 

5> 

(i, 

133 

,  . 

133 

III 

3S 

. . 

94 

. . 

69 

35 

66 

"39 

, , 

63 

98 

04 

136 

98 

iia 

,  , 

10 

.  . 

•  59 

.  89 

•• 

.  80 

III 

.  Ill 

.  70 

.  56 

.  131 

^  149  — 

Page. 

J'"*""! '. 8.36.46,     53 

Jamaica  Dogwood 1 1 3 

■'«"'" .'.".'. .,"...  59.    61 

K. 

KInealtherapy |-^ 

L. 

Laborde ,,, 

Lasigue  on  Migraine 3,^,     j, 

Laudanum  Enema  in  Sciatica j6 

L"'«'' '.'.'.'.'.'.'.'.'.'.  119 

Lcube g^ 

Legroux's  Treatment  of  Sciatica 136 

Liquor  Sedans 5, 

Locomotor  Ataxia go 

Massage ,3^ 

Mastodynla ,_ 

Maudsley ,_      ., 

Mcglin's  Pills .'.'.  ...'."."..'".'.'.'.".'.".'.'.'..'.'.■..■.'  1,3 

Menthol « 

Methyl  Chloride ^  .. ...... ...... ...... .     54 

Metastatic  Neuralgias .....     80 

Migraine ,, 

Mitchell,  S.  Weir .....,".,...     38 

Morphine j^g 

Injections ,q. 

Myalgia ..'....'.'......     85 

Narcotics 

. ,        ,         107 

Neuralgia,  Definition  of j 

General  Characteristics  of 3 

Treatment  of „. 

94 


—  ISO  — 

Page. 

Neuralgia,  Clinical  Description  of 5 

Pathogeny ' 

Classification ^9 

Causes •• ^* 

Idiopathic '9 

Symptomatic '^ 

Holopathic '9.     7i 

Ramicular '° 

Particular  Forms  of 3^ 

Facial 3' 

Central *' 

Cervico-occipital *' 

brachial 4' 

Intercostal '*'* 

Lumbo-abdomlnal 4» 

Visceral 57 

Reflex  and  Toxic 7i 

d  frigore "^"^ 

Uterine  and  Ovarian 59.  6o.     6i 

Neuritis ^5.    88 

Neuroses ''•    *■* 

Neurotic  Temperament *'• 

Neuromata ' 

Neurotomy  and  Neurectomy '37.  138 

Nerve  Stretching '37 

In  Sciatica 55 

Nlemeyer "*' 

Nitrite  of  Amyl "° 

In  Angina  Pectoris 7" 

Migraine 39 

Nltro-Glycerlne '3t 

in  Angina  Pectoris 7o 

Migraine ; 38 

Gastralgla ^4 


1, 


Page. 

. 

S 

7 

19 

. 

24 

. 

19 

19 

9. 

71 

20 

31 

. 

31 

91 

41 

42 

44 

48 

57 

71 

77 

)0, 

6i 

$5. 

88 

.2. 

24 

24 

•  ■  • 

89 

37. 

138 

137 

55 

42 

. . 

.  116 

, . 

•  7<^ 

■  39 

.  131 

.  70 

38 

, , 

.  64 

—  151  — 


Nothnagel . . . 
Nux  Vomica. 


Page. 
..  84 
. .   r23 


Oil  of  reppermint  in  Neuralgia ns 

Opium 

Osmic  Acid 

Osteocopic  Pains 


107 
140 

75 


Paroxysm  the  Neuralgic,  Treatment  of loi 

Pancoast,  Joseph j-g 

Peter,  Michel ^5    ,,y 

Phenacetin 102,  129!  130 

Phenic  Acid j.^ 

Phosphorus j^a 

Phthisis  in  its  Relation  to  Neuralgia 34 

Piscidia  Erythrina gj^  jjg 

Pseudo-Angina  Pectoris '     gg 

-Neuralgia 20 

Prognosis 


28 
93 


Prophylaxis  in  Neuralgia g. 

Pulsatilla gj 

Putnam,  J.J ag/jj'  jg 

Q- 


Quinine. 


in  Migraine. 


103,  120 
....     38 


Ranney.  Dr.  A.  L.,  on  Eye-Strain,  etc 72 

Revulsives '..... 

Rheumatic  Neuralgia 

Richardson,  Dr.  M.  H 

Romberg 


135 
77 

139 
35 


Pills  of  in  Mastodynia ^g 


.     >  -   '^'  ~  Page. 

1 20 

Salicin ' " " ^o 

Salol ■■■    4g 

Sciatica '     [^^   ^^  ,3^ 

Sfee,  Germain ^. 

on  Angina  Pectoris •  = 

30,  III 

Seguin 35.  3^ 

Senkler 26 

Sex  as  a  Predisposing  Cause •••••  ^^ 

SickHeadache ''i:"'\"- '.'.     06 

Sleep  in  the  Treatment  of  Neuralgia .■.'.'.".".'14,     16 

Spencer,  Herbert a 

Spring «2!» 

Strychnia jqj 

Surgical  Means  of  Cure. . . 44 

Svapiiia "  *. j,^ 

Swedish  Treatment  of  Neuralgia ■     ^^ 

Syphilitic  Neuralgia 

T. 

21    22        23 

Tableau  of  the  Neuralgias '."."'...'...'.  139 

Terrillon "  |  ^^ 

Tic  Douleureux " .  "  . .  126 

Tonga 1^5 

Toxic  Neuralgias 99 

Tonics ■ '. oft 

Traumatism  as  a  Cause  of  Neuralgia ..■■•■■  •  •  •  •  •    ^^^ 

Trousseau •  •  •  • " ; ,  ,„ 

his  Treatment  of  Migrame "" 

Turpentine  in  SciaUca. 

' 41.42.47.  50.     55 

Valleix 4 

his  Points  Douloureux J 

vSsr::;o;v5.;8:;9:'28;76:78;"8;;9i:"o;»6.«o:  13a 


tii^^mMtm'a'-*^' "i"*™ 


Page. 

.    I20 

.     60 
.     49 

I,    124 

.  65 

5,   III 

5.     38 
.     26 

•     39 

.     96 

4,     16 

a 

.  .  123 
.  .    lOI 

..  44 
..  134 
..     75 

82,      23 

. .  139 

...    32 

. . .  126 

...  75 

. ..  99 

. ..  28 

. ..  110 

...  no 

...  55 

50.     55 

...       4 

.    .     54 

I30,  133 


-  '53  - 

Veratna j 

Viburnum  Prunifolium g. 

Vinegar  of  Opium j^g 

Vulpian 

W. 

Watson,  Dr.  Eben j ^^ 

Worms  on  Diabetic  Neuralgia ^s 

Z. 

Zymotic  Neuralgias 


^ 


-:^,-..™r-_,.-4ii»l 


%? 


Eligible  Remedies  for  Neuralgia. 

AmonK  the  many  remedies  that  are  commended  (or  Neuralgia,  we 
may  m^nUon  for  internal  and  local  application  the  foUowmg.  wh.ch  we 

'"^^'''^      FOR  INTERNAL  ADMINISTRATION. 
Brown-Sequard's  Neuralgic  Idiopathic  .P»»»- 

Ext    Hyoscyamus,  2-3  gr.        Ext.  Con.um    ruit,  2-3  gr. 
Ext    lenatia    1-2  gr.  Ext.  Stramonium  seed,  i-5  gr. 

Fx  '  Od  urn    1-2  gr.  Ext.  Aconite  leaves.  1-3  gr. 

Exl:  Belladonna 'i-6  gr.  Ext.  Cannabis  Indica.  1-4  gr. 

Neuralgic  Idiopat.,  Brown  Sequard's,  Half  Strength. 

"'■  §r.n'eX*'t  ""■"      B..  AconU.  .»..,.  .-.  ... 
Morphine  sulph..  i-20  gr.         Strychnme,  1-30  gr. 
Arsenious  Acid,  1-20  gr. 

Neuralgic,  Without  Morphine,  Dr.  Gross'. 

r^r^hrll  Sedative  Compound.- A  scientific  substitute  for  certain 
copySe"  prepaSs  inThe  market.  The  active  constituents  are 
poKum  bromide,  chloral  hydrate,  gelsemmm  and  opium.  The  for 
""^^i?aS'?rfpa?erSedativ;Compound,  Formula  •;  B/' which  differs 
from  thetst?.amed  preparation  only  in  the  substitution  of  henbane  for 
the  opium  in  the  regular  formula.  ,„.,„<   „er 

PI    Ext    Guarana    U.  S.  P.-Guarana  contains  from  4  'o  5  P" 

is  indicated. 

FOR  LOCAL  APPLICATION. 

substance  derived  from  the  Japanese  pian^  loothache,  etc.,  and 

SS.?  enclosed  .o  Jre.en,  r.pid  voUuta.uon. 

l^r.''pe':r'fr.Lv.'c,i";r,,;=t:^^^^ 

of  Menthol.  .,^»,t»o    0     rr^ 

PARKE,  DAVIS  &  CO., 

DETROIT  AND  NEW  YORK. 


ilgia. 

leuralgia,  we 
ig,  which  we 

N. 


:ti,  1-5  gr. 
1-3  gr- 
I,  1-4  gr. 
Eth. 

t-2  gr. 


ite  for  certain 
nstituents  are 
im.     The  for- 

'  which  differs 
if  henbane  for 

)m  4  lo  5  per 
ny  other  drug. 
!  form,  so  that 
1  that  produced 
imedy  in  sick- 
erever  caffeine 


;amphoraceous 
nsis.  It  is  em- 
lache,  etc.,  and 
te  or  infusorial 
:eptable  substi- 
ire  it  to  be  kept 

)oxe5,  each  one 
local  application 

3., 

NEW  YORK. 


IN    EXPLANATION 

The  PhysJciaDS'  Leisure  Liliraiy. 

no  rt  ..l^r  l!**""  """*'"  "  "T  '^•■•""•""•'' '"  ""^  l'«'l.l(ctttion  of  ,n«dic«l  books      A8  vou 
no  d^,ub   know,  many  of  the  large  treatises  published,  which  sell  for  four  or  Ave  or 

publication  o  such  a  series,  calling  it  The  Pl.y.lrlan,.  fceUure  L.brarV 

PHYSICIANS'  LEISURE  LIBRARY 

PRICE.    PAPER,  25  CT?.  PER  COPY,  $2.50  PER  SETi  CLOTH,  50  CTS,  PER  COPY. 

$5,00  PER  SET. 


Inh^erg.  Inhalations  and  Inhalant! 
By  Beverley  Robinson,  M.  D. 

^sSn»J?i  °*  Ele't'-icity  in  the  Removal  of 

Va?ioui  Pi'ri,^  p!;  ^"'^u*''''  Treatment  of 
variou}  Facial  Blemishes. 
By  Geo.  Henry  Fox,  M.  D. 
New  Medications,  in  2  Vols. 

By  Dujardin-Beaumetr,  M   D 

'■''•B^°sl'nJSeT^Vt'Sn7ll°'D^.'^°"""- 

Antiieptic  Midwifery. 

By  Henry  J.  Garri({ues,  M.  D. 


SERIES  I. 


On  the  Determination  of  the  Necessity  for 
Wearing  Glasses. 
By  D.  B.  St.  John  Roos     M.  D. 

The  Physiological, Patholoificsl  and  Ther- 
apeutic Effects  of  Compressed  Air. 
By  Andrew  H.  Smith,  M.  D. 

*^™ nl!  ur-'i'  V.^  ContagiousOphthalmla. 
By  W.  F.  Mittendorf,  M.  D. 

Practical  Bacteriology. 

By  Thomas  E.  Satterthwaile,  M.  D 

Pregnancy,    Parturition,    the    Puerpera 

'*'y?i-"aii''Ff'&d§:'sf*'5"*' 


mT" 


SERIES  II. 


Thy  pjagnotitand  Treatment  of  Htemor- 

By  Cha».  B.  Kelsey,  M.  D. 
Dlteawiof  the  Heart,  in  2  Voli. 

By  Oujardin-Heaumeu,  M.  D. 

Translated  by  E.  P.  Hurd,  M.  D. 
The  Modern  Treatment  of  Diarrhoea  and 
Dytentery.  ^ 

By  A.  B.  Palmer,  M.  D. 
Inteitinal  Dieeaeeeof  Children,  in  2  Voitt 

By  A.  Jacobi,  M.  D. 


^"TlnaVttcraSS'fi'.S.tftSS?'^;  D. 
The  Modern  Treatment  of  Pleurley  and 
*^''8;;'&"^;Garland.M.D. 

'»'*Tfr?iI!'n*dS*n'iy."Jtt'i!i[.D. 

^"•ijYaVrffifSfeV-.  l*T 
Translated  by  E.  P.  Hurd,  M.  D, 


SERIES  III. 


Abdominal  SurBtery 

By  Hal  C.  Wyman,  M.  D. 

Dleeases  of  the  Liver. 

By  Dujardin-Reaumelz,  M.D. 

Hytteria  and  Epilepsy. 

By  J.  Leonard  Coming,  M.  D. 

Diseases  of  the  Kidney. 

By  Dujardin-Beaumetz,  M.  D. 

The  Theory  and  Practice  of  the  Ophthal- 
moscope. 

By  J.  Herbert  Claiborne,  Jr.,  M.  D. 

Modern  Treatment  of  Bright's  Disease. 
By  Alfred  L.  Loomis,  M.  D. 


Clinical  Lectures  on  Certain  Diseases  of 
Nervous  System. 
By  Prof.  J.  M.  Charcot,  M.  D. 
The  Radical  Cure  of  Hernia. 

By  Henry  O.  Marcy,  A.  M.,  M.  D., 
L.  L.  D. 

""llr'Wl^i^mA  Hammond,  M.  D. 
Dyspepsia. 

By  Frank  Woodbury,  M.  D. 
The  Treatment  of  the  Morphia  Habit. 

By  Erlenmeyer. 
The  Etiologlyi  Diagnosis  and  Therapy  of 

By  Prof.  \i.  von  '.liemssen. 
TransUted  by  D.  J.  Doherty,  M.  D. 


jrrelated  to 
romen. 


Nervous  Syphilis. 

By  H.  C.  Wood.  M.  D 
Education  and^  Culture  as  ooi 

"'•'By'X.H  Smith,  M.D. 

*XirnS2nWeU;?£.M.D. 
Seme  Major  and  Minor  Fallacies  oon 
oeming  Syphilis. 

By  E.  L.  Keyes.  M.  D. 

»'>«^^y*{Ci"m'2llli?lirbricon. 


SERIES  IV. 

Practical  Points. in  the  Management  of 


''•''ff;''!:  P.  Hurd,  M.D. 
""•fe^^iTe^^SSlierlee.M.D. 

Electricity,  its  application  in  Medicine. 
By  Wellington  Adams,  M.  D. 

^•"te^^.'l^lBosworth.M.D. 

*-'«';w«'rsa'*^'S8rt&^k.M.D. 


Bm-iM  ir*HU  6«  U»u0d  0N«  •  month,  bf/imning  with  jre««Ms»«r,  1»»». 

GEORGE  S.  DAVIS,  Publisher, 

O.  Boac  -WTO.  Detroit,  ^tfloH- 


P 


■^■^^fc 

• 

1 

uniiton,  m.'  D. 

>f  PKurity  and 

D. 

%.D. 

S!"«1:d. 

i 

IntTOli. 

lurd,  M.  D. 

t^  *%...-...  .J 

) 

3t,  M.  D. 

,'*A.  M.,  M.  D., 

lond,  M.  D. 

,  M.D. 
rphia  Habit, 

and  Tliarapy  of 

assen. 
toherty,  M.  D. 


Managamant  of 


D. 

riee,  M.  D. 
n  in  Madiclna, 
aa,  M.  D. 

M.D. 
temher,  1890. 


r. 

It,  ^^OaUx. 


— -"-• ^•'"  f*'.*^  T- 


